Promoting Sustained Breastfeeding of Infants at Risk for Asthma: Explaining the "Active Ingredients" of an Effective Program Using Intervention Mapping.

Infants whose parents and/or siblings have a history of asthma or allergy may profit from receiving exclusive breastfeeding during the first 6 months of life. This is expected to diminish the chance of developing childhood asthma and/or atopic disease. Ongoing breastfeeding for 6 months seems challenging for many women. An educational program was developed using Intervention Mapping as a logic model to guide development and was found successful in improving breastfeeding rates at 6 months postpartum, improving knowledge and beliefs about breastfeeding for 6 months, after exposure to the program compared to controls. Intervention elements included an evidence- and theory-based booklet addressed during pre- and postnatal home visits by trained assistants. This paper elucidates the inner workings of the program by systematically describing and illustrating the steps for intervention development.

Development of a theory and evidence-based program to promote community treatment of fevers in children under five in a rural district in Southern Ghana: An intervention mapping approach.

BACKGROUND: This paper describes the development and implementation of a program to promote prompt and appropriate care seeking for fever in children under the age of five. Designed as a multicomponent program, the intervention comprises elements to influence the behavior of caregivers of children, Community Health Workers, professional health care providers and the wider community. METHODS: Following the six fundamental steps of the Intervention Mapping protocol, we involved relevant stakeholders from the commencement of planning to program end. The IM protocol also recommends various behavior change methods to guide intervention development. RESULTS: The intervention components implemented were successful in achieving program goals. For example, the intervention resulted in the primary outcome of reductions in all-cause mortality of 30% and 44%, among children treated with an antimalarial and those treated with the antimalarial plus an antibiotic respectively. Most Community Health Workers were retained on the program, with an attrition rate of 21.2% over a period of 30 months and the Community Health Workers rate of adherence to performance guidelines was high at 94.6%. CONCLUSION: We were able to systematically develop a theory- and evidence-based health promotion program based on the Intervention Mapping protocol. This article contributes to the response to recent calls for a more detailed description of the development of interventions and trials. The intervention mapping approach can serve as a guide for others interested in developing community- based health interventions in similar settings.

Use of Theory in Behavior Change Interventions.

OBJECTIVE: Theory use may enhance effectiveness of behavioral interventions, yet critics question whether theory-based interventions have been sufficiently scrutinized. This study applied a framework to evaluate theory use in physical activity interventions for breast cancer survivors. The aims were to (1) evaluate theory application intensity and (2) assess the association between extensiveness of theory use and intervention effectiveness. METHODS: Studies were previously identified through a systematic search, including only randomized controlled trials published from 2005 to 2013, that addressed physical activity behavior change and studied survivors who were <5 years posttreatment. Eight theory items from Michie and Prestwich's coding framework were selected to calculate theory intensity scores. Studies were classified into three subgroups based on extensiveness of theory use (Level 1 = sparse; Level 2 = moderate; and Level 3 = extensive). RESULTS: Fourteen randomized controlled trials met search criteria. Most trials used the transtheoretical model ( n = 5) or social cognitive theory ( n = 3). For extensiveness of theory use, 5 studies were classified as Level 1, 4 as Level 2, and 5 as Level 3. Studies in the extensive group (Level 3) had the largest overall effect size ( g = 0.76). Effects were more modest in Level 1 and 2 groups with overall effect sizes of g = 0.28 and g = 0.36, respectively. CONCLUSIONS: Theory use is often viewed as essential to behavior change, but theory application varies widely. In this study, there was some evidence to suggest that extensiveness of theory use enhanced intervention effectiveness. However, there is more to learn about how theory can improve interventions for breast cancer survivors.

Community perceptions and practices of treatment seeking for childhood pneumonia: a mixed methods study in a rural district, Ghana.

BACKGROUND: The World Health Organization recommends community case management of malaria and pneumonia for reduction of under-five mortality in developing countries. Caregivers' perception and understanding of the illness influences the care a sick child receives. Studies in Ghana and elsewhere have routinely shown adequate recognition of malaria by caregivers. Similarly, evidence from Asia and some African countries have shown adequate knowledge on pneumonia. However, in Ghana, little has been documented about community awareness, knowledge, perceptions and management of childhood pneumonia particularly in the Dangme West district. Therefore this formative study was conducted to determine community perceptions of pneumonia for the purpose of informing the design and implementation of context specific health communication strategies to promote early and appropriate care seeking behaviour for childhood pneumonia. METHODS: A mixed method approach was adopted. Data were obtained from structured interviews (N = 501) and eight focus group discussions made up of 56 caregivers of under-fives and eight community Key Informants. Descriptive and inference statistics were used for the quantitative data and grounded theory to guide the analysis of the qualitative data. RESULTS: Two-thirds of the respondents had never heard the name pneumonia. Most respondents did not know about the signs and symptoms of pneumonia. For the few who have heard about pneumonia, causes were largely attributed to coming into contact with cold temperature in various forms. Management practices mostly were self-treatment with home remedies and allopathic care. CONCLUSION: The low awareness and inadequate recognition of pneumonia implies that affected children may not receive prompt and appropriate treatment as their caregivers may misdiagnose the illness. Adequate measures need to be taken to create the needed awareness to improve care seeking behaviour.

A taxonomy of behaviour change methods: an Intervention Mapping approach.

In this paper, we introduce the Intervention Mapping (IM) taxonomy of behaviour change methods and its potential to be developed into a coding taxonomy. That is, although IM and its taxonomy of behaviour change methods are not in fact new, because IM was originally developed as a tool for intervention development, this potential was not immediately apparent. Second, in explaining the IM taxonomy and defining the relevant constructs, we call attention to the existence of parameters for effectiveness of methods, and explicate the related distinction between theory-based methods and practical applications and the probability that poor translation of methods may lead to erroneous conclusions as to method-effectiveness. Third, we recommend a minimal set of intervention characteristics that may be reported when intervention descriptions and evaluations are published. Specifying these characteristics can greatly enhance the quality of our meta-analyses and other literature syntheses. In conclusion, the dynamics of behaviour change are such that any taxonomy of methods of behaviour change needs to acknowledge the importance of, and provide instruments for dealing with, three conditions for effectiveness for behaviour change methods. For a behaviour change method to be effective: (1) it must target a determinant that predicts behaviour; (2) it must be able to change that determinant; (3) it must be translated into a practical application in a way that preserves the parameters for effectiveness and fits with the target population, culture, and context. Thus, taxonomies of methods of behaviour change must distinguish the specific determinants that are targeted, practical, specific applications, and the theory-based methods they embody. In addition, taxonomies should acknowledge that the lists of behaviour change methods will be used by, and should be used by, intervention developers. Ideally, the taxonomy should be readily usable for this goal; but alternatively, it should be clear how the information in the taxonomy can be used in practice. The IM taxonomy satisfies these requirements, and it would be beneficial if other taxonomies would be extended to also meet these needs.

Intervention Mapping to Adapt Evidence-Based Interventions for Use in Practice: Increasing Mammography among African American Women.

This paper describes and demonstrates the use of the systematic planning process, Intervention Mapping, to adapt an evidence-based public health intervention (EBI). We used a simplified version of Intervention Mapping (IM Adapt) to increase an intervention's fit with a new setting and population. IM Adapt guides researchers and practitioners in selecting an EBI, making decisions about whether and what to adapt, and executing the adaptation while guarding the EBI's essential elements (those responsible for effectiveness). We present a case study of a project in which we used IM Adapt to find, adapt, implement, and evaluate an EBI to improve mammography adherence for African American women in a new practice setting in Houston, Texas. IM Adapt includes the following (1) assess needs and organizational capacity; (2) find EBIs; (3) plan adaptations based on fit assessments; (4) make adaptations; (5) plan for implementation; and (6) plan for evaluation of the adapted EBI. The case study shows an example of how public health researchers and practitioners can use the tool to make it easier to find and use EBIs, thus encouraging greater uptake. IM Adapt adds to existing dissemination and adaptation models by providing detailed guidance on how to decide on effective adaptation, while maintaining the essential elements of the EBI.

Evaluation of the Effectiveness and Implementation of an Adapted Evidence-Based Mammography Intervention for African American Women.

Breast cancer mortality disparities continue, particularly for uninsured and minority women. A number of effective evidence-based interventions (EBIs) exist for addressing barriers to mammography screening; however, their uptake and use in community has been limited. Few cancer-specific studies have evaluated adapted EBIs in new contexts, and fewer still have considered implementation. This study sought to (1) evaluate the effectiveness of an adapted mammography EBI in improving appointment keeping in African American women and (2) describe processes of implementation in a new practice setting. We used the type 1 hybrid design to test effectiveness and implementation using a quasi-experimental design. Logistic regression and intent-to-treat analysis were used to evaluate mammography appointment attendance. The no-show rate was 44% (comparison) versus 19% (intervention). The adjusted odds of a woman in the intervention group attending her appointment were 3.88 (p < 0.001). The adjusted odds of a woman attending her appointment in the intent-to-treat analysis were 2.31 (p < 0.05). Adapted EBI effectiveness was 3.88 (adjusted OR) versus 2.10 (OR) for the original program, indicating enhanced program effect. A number of implementation barriers and facilitators were identified. Our findings support previous studies noting that sequentially measuring EBI efficacy and effectiveness, followed by implementation, may be missing important contextual information.

Treating fever in children under 5 years of age: caregiver perceptions of community health worker services in Dangme West district, Ghana.

BACKGROUND: Integrated community case management of childhood illnesses is a key strategy to help reduce mortality in children under 5 years; particularly those with difficult access to treatment. However, the success of such strategies depends on community utilization of services. This study assessed community utilization, perceptions and related factors of community health worker services. METHODS: Data were gathered from a cross-sectional survey among 562 caregivers and focus group discussions among 84 caregivers. Factors related to utilization of community health workers (CHWs) for management of childhood fevers were analyzed using logistic regression and focus group discussions to explore caregiver perceptions of CHW activities. RESULTS: Utilization of CHWs for management of fever in under-5s was 59.4%. Caregivers who were exposed to the communication intervention were about four times more likely to use the services of the CHWs compared to those who were not exposed (OR 3.79; 95% CI: 2.62-5.49; p<0.001). Farmers were 84% more likely to use CHW services for children sick with fever compared to those who were unemployed (OR 1.84; 95% CI: 1.00-3.39; p=0.05). Caregiver perceptions of the program were generally positive; most caregivers expressed satisfaction with the CHW services, citing prompt treatment, friendliness and free medicines. Male involvement in the CHW program was comparatively low. CONCLUSIONS: Dissemination of information among priority groups can enhance utilization of CHW services. Exploring the perspective of both men and women to gain in-depth understanding on their views on male involvement will be useful for planning appropriate strategies to get more males involved in community-based child health programs.

Validation of self-reported post-treatment mammography surveillance among breast cancer survivors by electronic medical record extraction method.

Little is known about validity of self-reported mammography surveillance among breast cancer survivors. Most studies have focused on accuracy among healthy, average-risk populations and none have assessed validity by electronic medical record (EMR) extraction method. To assess validity of survivor-reported mammography post-active treatment care, we surveyed all survivors diagnosed 2004-2009 in an academic hospital cancer registry (n = 1441). We used electronic query and manual review to extract EMR data. Concordance, sensitivity, specificity, positive predictive value, and report-to-records ratio were calculated by comparing survivors' self-reports to data from each extraction method. We also assessed average difference in months between mammography dates by source and correlates of concordance. Agreement between the two EMR extraction methods was high (concordance 0.90; kappa 0.70), with electronic query identifying more mammograms. Sensitivity was excellent (0.99) regardless of extraction method; concordance and positive predictive value were good; however, specificity was poor (manual review 0.20, electronic query 0.31). Report-to-records ratios were both over 1 suggesting over-reporting. We observed slight forward telescoping for survivors reporting mammograms 7-12 months prior to survey date. Higher educational attainment and less time since mammogram receipt were associated with greater concordance. Accuracy of survivors' self-reported mammograms was generally high with slight forward telescoping among those recalling their mammograms between 7 and 12 months prior to the survey date. Results are encouraging for clinicians and practitioners relying on survivor reports for surveillance care delivery and as a screening tool for inclusion in interventions promoting adherence to surveillance guidelines.

Taking the next step: a systematic review and meta-analysis of physical activity and behavior change interventions in recent post-treatment breast cancer survivors.

Research has shown that recent post-treatment breast cancer survivors face significant challenges around physical activity as they transition to recovery. This review examined randomized controlled trials targeting physical activity behavior change in breast cancer survivors <5 years post-treatment and described (1) characteristics of interventions for breast cancer survivors as well as (2) effect size estimates for these studies. A systematic search was conducted following PRISMA guidelines with Medline, PubMed, PsycINFO, CINAHL, and Scopus databases. Data were abstracted for primary intervention strategies and other details (e.g., setting, duration, theory use). A subgroup analysis was conducted to assess intensity of exercise supervision/monitoring and intervention effectiveness. The search produced 14 unique behavior intervention trials from the US and abroad published 2005-2013. The mean sample size was 153 participants per study. All interventions included moderate-intensity activities plus various behavioral change strategies. Most interventions were partially or entirely home based. The overall standardized mean difference was 0.47 (0.23, 0.67) with p < 0.001. Most interventions were effective in producing short-term behavior changes in physical activity, but varied greatly relative to intervention strategies and intensity of supervision/monitoring. Highly structured interventions tended to produce larger behavior change effects overall, but many larger effect sizes came from interventions supported by phone counseling or e-mail. We observed that 'more' may not be better in terms of direct supervision/monitoring in physical activity behavior interventions. This may be important in exploring less resource-intensive options for effective behavior change strategies for recent post-treatment survivors.

Grounding evidence-based approaches to cancer prevention in the community: a case study of mammography barriers in underserved African American women.

When community health planners select an evidence-based intervention that has been developed and tested in one situation and adapt it for use in a different situation or community, best practice suggests needs assessment and formative research in the new setting. Cancer prevention planners who are interested in adopting and adapting evidence-based approaches need to base their choices on a sound understanding of the health or behavioral risk problem in which they mean to intervene. This requires a balancing act of weighing community information against a broader perspective from the scientific literature and using the combination to identify and adapt an evidence-based intervention program that is likely to be effective in the new setting. This report is a case study of a community and organizational assessment conducted as a foundation for selecting and recommending adaptation of an evidence-based intervention for improving mammography appointment attendance. We used an inductive sequential exploratory mixed-methods design to inform this process. The process provides a model for formative research grounding evidence-based practice for cancer control planners. Future studies that incorporate findings from needs assessment into the adaptation of the selected intervention program may promote the effective dissemination of evidence-based programs.

Finding theory- and evidence-based alternatives to fear appeals: Intervention Mapping.

Fear arousal-vividly showing people the negative health consequences of life-endangering behaviors-is popular as a method to raise awareness of risk behaviors and to change them into health-promoting behaviors. However, most data suggest that, under conditions of low efficacy, the resulting reaction will be defensive. Instead of applying fear appeals, health promoters should identify effective alternatives to fear arousal by carefully developing theory- and evidence-based programs. The Intervention Mapping (IM) protocol helps program planners to optimize chances for effectiveness. IM describes the intervention development process in six steps: (1) assessing the problem and community capacities, (2) specifying program objectives, (3) selecting theory-based intervention methods and practical applications, (4) designing and organizing the program, (5) planning, adoption, and implementation, and (6) developing an evaluation plan. Authors who used IM indicated that it helped in bringing the development of interventions to a higher level.

Preparing adolescents with chronic disease for transition to adult care: a technology program.

BACKGROUND: Adolescents with chronic disease (ACD) must develop independent disease self-management and learn to communicate effectively with their health care team to transition from pediatric to adult-oriented health care systems. Disease-specific interventions have been implemented to aid specific ACD groups through transition. A generic approach might be effective and cost-saving. METHODS: Eighty-one ACD, aged 12 to 20 years, were recruited for a randomized clinical trial evaluating an 8-month transition intervention (MD2Me). MD2Me recipients received a 2-month intensive Web-based and text-delivered disease management and skill-based intervention followed by a 6-month review period. MD2Me recipients also had access to a texting algorithm for disease assessment and health care team contact. The intervention was applicable to adolescents with diverse chronic illnesses. Controls received mailed materials on general health topics. Disease management, health-related self-efficacy, and health assessments were performed at baseline and at 2 and 8 months. Frequency of patient-initiated communications was recorded over the study period. Outcomes were analyzed according to assigned treatment group over time. RESULTS: MD2Me recipients demonstrated significant improvements in performance of disease management tasks, health-related self-efficacy, and patient-initiated communications compared with controls. CONCLUSIONS: Outcomes in ACD improved significantly among recipients of a generic, technology-based intervention. Technology can deliver transition interventions to adolescents with diverse chronic illnesses, and a generic approach offers a cost-effective means of positively influencing transition outcomes. Further research is needed to determine whether improved short-term outcomes translate into an improved transition for ACD.

Factors related to retention of community health workers in a trial on community-based management of fever in children under 5 years in the Dangme West District of Ghana.

BACKGROUND: In resource-constrained settings of developing countries, promotion of community-based health interventions through community health workers (CHWs) is an important strategy to improve child health. However, there are concerns about the sustainability of such programmes owing to the high rate of CHW attrition. This study examined factors influencing retention of volunteer CHWs in a cluster randomised trial on community management of under-5 fever in a rural Ghanaian district. METHODS: Data were obtained from structured interviews (n=520) and focus group discussions (n=5) with CHWs. Factors influencing CHWs' decisions to remain or leave the programme were analysed using a probit model, and focus group discussion results were used to elucidate the findings. RESULTS: The attrition rate among CHWs was 21.2%. Attrition was comparatively higher in younger age groups (25.9% in 15-25 years group, 18.2% in 26-45 years group and 16.5% in ≥46 years group). Approval of a CHW by the community (p<0.001) and the CHW's immediate family (p<0.05) were significant in influencing the probability of remaining in the programme. Motivation for retention was related to the desire to serve their communities as well as humanitarian and religious reasons. CONCLUSION: The relatively moderate rate of attrition could be attributed to the high level of community involvement in the selection process as well as other aspects of the intervention leading to high community approval and support. Attention for these aspects could help improve CHW retention in community-based health interventions in Ghana, and the lessons could be applied to countries within similar settings.

Cultural practices and sexual risk behaviour among adolescent orphans and non-orphans: a qualitative study on perceptions from a community in Western Kenya.

BACKGROUND: This study explored community perceptions of cultural beliefs and practices that may increase sexual risk behaviour of adolescents, to understand more about meaning they hold within the culture and how they expose adolescent orphans and non-orphans to higher risks in a high HIV and teenage pregnancy prevalence context. METHODS: Using a qualitative descriptive cross-sectional design 14 focus group discussions were conducted with 78 adolescents and 68 parents/guardians purposively selected to represent their communities. Thirteen key informant interviews were also conducted with community leaders, health care and child welfare workers, and adolescents who were also selected purposively. The two methods were used to explore how cultural beliefs and practices predispose adolescent orphans and non- orphans to risky sexual behaviours. Data were analysed through line-by-line coding, grouped into families and retrieved as themes and sub-themes. RESULTS: Identified cultural practices that predisposed adolescents orphans and non-orphans to risky sexual behaviours included: adolescent sleeping arrangements, funeral ceremonies, replacing a deceased married daughter with her younger sister in marriage, widow inheritance among boys, early marriage among girls, and preference for boys/sons. Cultural risks perceived to equally affect both orphans and non-orphans were sleeping arrangements, funeral ceremonies, and sister replacement. Factors associated more with orphans than non-orphans were widow inheritance among boys and a preference for boy over girl children. CONCLUSIONS: Adolescent sexual risk reduction programs should be developed considering the specific cultural context, using strategies that empower communities to challenge the widely accepted cultural norms that may predispose young people in general to sexual risks while targeting those that unequally influence orphans.

Factorial validity and invariance of four psychosocial constructs of colorectal cancer screening: does screening experience matter?

BACKGROUND: Few studies have examined the psychometric properties and invariance of scales measuring constructs relevant to colorectal cancer screening (CRCS). We sought to: (i) evaluate the factorial validity of four core constructs associated with CRCS (benefits, barriers, self-efficacy, and optimism); and (ii) examine measurement invariance by screening status (currently screened, overdue, never screened). METHODS: We used baseline survey data from a longitudinal behavioral intervention trial to increase CRCS among U.S. veterans. Respondents were classified as currently screened (n = 3,498), overdue (n = 418), and never screened (n = 1,277). The measurement model was developed using a random half of the sample and then validated with the second half of the sample and the full baseline sample (n = 5,193). Single- and multi-group confirmatory factor analysis was used to examine measurement invariance by screening status. RESULTS: The four-factor measurement model demonstrated good fit. Factor loadings, item intercepts, and residual item variance and covariance were invariant when comparing participants never screened and overdue for CRCS, indicating strict measurement invariance. All factor loadings were invariant among the currently screened and overdue groups. Only the benefits scale was invariant across current screeners and never screeners. Non-invariant items were primarily from the barriers scale. CONCLUSION: Our findings provide additional support for the construct validity of scales of CRCS benefits, barriers, self-efficacy, and optimism. A greater understanding of the differences between current and never screeners may improve measurement invariance. IMPACT: Measures of benefits, barriers, self-efficacy, and optimism may be used to specify intervention targets and effectively assess change pre- and post-intervention across screening groups.

The development of scientific communication skills: a qualitative study of the perceptions of trainees and their mentors.

PURPOSE: Scientific communication, both written and oral, is the cornerstone of success in biomedical research, yet formal instruction is rarely provided. Trainees with little exposure to standard academic English may find developing scientific communication skills challenging. In this exploratory, hypothesis-generating qualitative study, the authors examined the process by which mentored junior researchers learn scientific communication skills, their feelings about the challenges, and their mentor's role in the process. METHOD: In 2010, the authors conducted semistructured focus groups and interviews to explore research trainees' and faculty mentors' perceptions and practices regarding scientific communication skills development, as part of the development phase of a larger quantitative study. The facilitator took detailed notes and verified their accuracy with participants during the sessions; a second member of the research team observed and verified the recorded notes. Three coders performed a thematic analysis, and the other authors reviewed it. RESULTS: Forty-three trainees and 50 mentors participated. Trainees and mentors had diverging views on the role of mentoring in fostering communication skills development. Trainees expressed varying levels of self-confidence but considerable angst. Mentors felt that most trainees have low self-confidence. Trainees expressed interest in learning scientific communication skills, but mentors reported that some trainees were insufficiently motivated and seemed resistant to guidance. Both groups agreed that trainees found mentors' feedback difficult to accept. CONCLUSIONS: The degree of distress, dissatisfaction, and lack of mutual understanding between mentors and trainees was striking. These themes have important implications for best practices and resource development.

Validity of self-reported genetic counseling and genetic testing use among breast cancer survivors.

INTRODUCTION: Despite the value of genetic counseling (GC) and genetic testing (GT) for high-risk breast cancer survivors, little is known about their uptake and validity of self-report data. This study evaluated the accuracy of self-reported genetic counseling and testing rates among breast cancer survivors. METHODS: The current analysis focused on Stage 0-III female breast cancer survivors who were identified from an academic medical center's cancer registry and responded to a mailed survey (N = 452). Self-reported rates of GC and GT were validated using information from the electronic medical record. RESULTS: Overall, 30.8 % of survivors reported having seen a genetic counselor in the time period after their breast cancer diagnosis and 33.6 % noted having a genetic test. Concordance and specificity were good for both genetic questions; concordance agreements ranged from 86-88 %, while specificity was 83-86 %. Sensitivity (97-98 %) and negative predictive values (99 %) were excellent, while the positive predictive values for both GC and GT were poor (59-63 %). CONCLUSIONS: Among breast cancer survivors, self-reports of GC and GT were generally accurate, although a subset of respondents overestimated genetic service utilization. Future work should focus on validating GC and GT self-reports in medically underserved populations. IMPLICATIONS FOR CANCER SURVIVORS: Genetic counseling and testing are valuable aspects of survivorship care for high-risk breast cancer survivors; accurate understanding of their use is important for survivors, clinicians, and researchers.

Understanding orphan and non-orphan adolescents' sexual risks in the context of poverty: a qualitative study in Nyanza Province, Kenya.

BACKGROUND: Some studies show orphanhood to be associated with increased sexual risk-taking while others have not established this relationship, but have found factors other than orphanhood as predictors of sexual risk behaviours and outcomes among adolescents. This study examines community members' perceptions of how poverty influences adolescent sexual behaviour and outcomes in four districts of Nyanza Province, Kenya. METHODS: Eight study sites within the four districts were randomly selected. Focus group discussions were conducted with a purposive sample of adolescents, parents and caregivers. Key informant interviews were undertaken with a purposive sample of community leaders, child welfare and healthcare workers, and adolescents. The two methods elicited information on factors perceived to predispose adolescent orphans and non-orphans to sexual risks. Data were analysed through line-by-line coding, grouped into families and retrieved as themes and sub-themes. RESULTS: Participants included 147 adolescents and parents/caregivers in 14 focus groups and 13 key informants. Poverty emerged as a key predisposing factor to sexual risk behaviour among orphans and non-orphans. Poverty was associated with lack of food, poor housing, school dropout, and engaging in income generating activities, all of which increase their vulnerability to transactional sex, early marriage, sexual experimentation, and the eventual consequences of increased risk of unintended pregnancies and STI/HIV. CONCLUSION: Poverty was perceived to contribute to increasing sexual risks among orphan and non-orphan adolescents through survival strategies adopted to be able to meet their basic needs. Policies for prevention and intervention that target adolescents in a generalized poverty and HIV epidemic should integrate economic empowerment for caregivers and life skills for adolescents to reduce vulnerabilities of orphan and non-orphan adolescents to sexual risk behaviour.

Receipt of recommended surveillance among colorectal cancer survivors: a systematic review.

PURPOSE: Regular surveillance decreases the risk of recurrent cancer in colorectal cancer (CRC) survivors. However, studies suggest that receipt of follow-up tests is not consistent with guidelines. This systematic review aimed to: (1) examine receipt of recommended post-treatment surveillance tests and procedures among CRC survivors, including adherence to established guidelines, and (2) identify correlates of CRC surveillance. METHODS: Systematic searches of Medline, PubMed, PsycINFO, CINAHL Plus, and Scopus databases were conducted using terms adapted for each database's keywords and subject headings. Studies were screened for inclusion using a three-step process: (1) lead author reviewed abstracts of all eligible studies; (2) coauthors reviewed random 5 % samples of abstracts; and (3) two sets of coauthors reviewed all "maybe" abstracts. Discrepancies were adjudicated through discussion. RESULTS: Thirty-four studies are included in the review. Overall adherence ranged from 12 to 87 %. Within the initial 12 to 18 months post-treatment, adherence to recommended office visits was 93 %. Adherence ranged from 78 to 98 % for physical exams, 18-61 % for colonoscopy, and 17-71 % for carcinoembryonic antigen (CEA) testing. By 2 to 3 years post-treatment, cumulative adherence ranged from 70 to 88 % for office visits, 89-93 % for physical exams, 49-94 % for colonoscopy, and 7-79 % for CEA testing. Between 18 and 28 % of CRC survivors received greater than recommended overall surveillance; overuse of physical exams (42 %), colonoscopy (24-76 %), and metastatic disease testing (1-29 %) was also prevalent. Studies of correlates of CRC surveillance focused on sociodemographic and disease/treatment characteristics, and patterns of association were inconsistent across studies. CONCLUSIONS: Deviation from surveillance recommendations includes both under- and overuse. Examination of modifiable determinants is needed to inform interventions targeting appropriate and timely receipt of recommended surveillance. IMPLICATIONS FOR CANCER SURVIVORS: Among CRC survivors, it remains unclear what modifiable psychosocial factors are associated with the observed under- and overuse of surveillance. Understanding and intervening with these psychosocial factors is critical to improving adherence to guideline-recommended surveillance and thereby reducing mortality among this group of survivors.