Jeroen De Man

Background: Social norms around PrEP act as both barriers to and stimulants of the use of PrEP across a wide range of target populations, yet remain relatively understudied. To stimulate theoretical innovation and provide a quantitative check for qualitative findings, we integrate norm types from the Behavioral Models (BM) and the Social Norms Approach (SNA) into the socio-ecological model (SEM) and analyze their relationship with PrEP-intention. We include attitude and role belief at the individual level, injunctive norms at the interpersonal level and descriptive norms and self-comparison to peers at the community level. Methods: The data were drawn from a survey on sexual health distributed on social media by Flemish MSM community organizations from October 19 ^th, 2022, to December 19 ^th, 2022, resulting in a total convenience sample of 610. Structural Equation Modelling analyses, including confirmatory factor analysis of the latent variables and path analysis of the relationship between norm types and PrEP intention, were conducted on a convenience sample of 350 Belgian MSM who were not living with HIV. Results: At the individual level, attitude towards PrEP was positively and moderately to strongly associated with intention, while role belief that ‘It is inappropriate for someone with my relationship(s) to use PrEP’ was negatively and moderately to strongly associated with intention. At the interpersonal level, injunctive norms, the expectation of a positive reaction to the respondent’s PrEP use, were positively and moderately to strongly associated with intention. At the community level, descriptive norms, thinking more peers use PrEP, were positively and weakly associated with intention. While self-comparison to peers, estimating one’s own sexual behaviour as safer than peers, was negatively and weakly associated with intention. Conclusion: All norm types included in the analysis, at the individual level (attitude and role belief), interpersonal level (injunctive norms), and the community level (descriptive norms and self-comparison to peers), were associated with PrEP-intention among MSM. Most PrEP interventions target cognition, while our analysis shows significant untapped potential for norm-based interventions to increase intention to use PrEP.

In 2023, an estimated 39.9 million people globally were living with HIV, including 7.7 million in South Africa. Adherence to antiretroviral therapy (ART) is crucial for health outcomes, yet remains challenging. Households may shape health behaviours, including ART adherence. This study evaluated a household-level intervention to improve ART adherence in Cape Town, South Africa, which aimed to promote HIV competency for participants and their households. Baseline data were collected from 316 participants in 12 clinics (May 2021 - May 2022), with endline data from 198 participants (December 2021 - July 2022). Cluster-level analysis and mixed-effects models, with multiple imputation and complete case approaches, were utilised. At endline, there was evidence of a difference between control and intervention arms for following the ART schedule (aOR: 3.88, t = 2.62, p = 0.009), and taking ART on time (aOR: 2.28, t = 2.54, p = 0.01). Household-based interventions may have an impact on ART adherence, and should be considered in future adherence research, programming, and interventions. CLINICAL TRIAL REGISTRATION: Clinical Trial Number: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019.

Despite national declines in HIV prevalence, adolescent girls and young women (AGYW) in South Africa continue to face a disproportionate burden of HIV infection. The syndemic theory provides a framework for understanding how interconnected epidemics such as alcohol use disorders, violence and HIV cluster together and reinforce each other. Using this theory, we aimed to test and explore the relationship between alcohol use and HIV risk and infection amongst AGYW in high HIV-burdened communities in South Africa. Data for this study were drawn from a mixed methods impact evaluation of a combination HIV prevention programme implemented across eight provinces in South Africa. A household survey was conducted among AGYW aged 15─24 years in the 12 intervention sub-districts selected by the Global Fund and 12 matching comparison sub-districts. Dried blood spot specimens were collected to test for HIV; alcohol use and sexual behaviours were reported through a self-completed electronic questionnaire. Generalised linear regression models were used to assess the relationship between alcohol use and HIV risk and infection as well as sexual risk behaviours and hazardous drinking. A subsample of 68 AGYW participated in qualitative in-depth interviews. Interview transcripts were translated into English and analysed using thematic analysis. Of the 5025 survey participants, 10% were living with HIV, and 35% engaged in hazardous drinking. No significant association was found between alcohol use and HIV risk or infection. However, a positive association was found between hazardous drinking and sexual violence (OR=1.51; 95% CI: 1.20─1.90), condomless sex (OR=1.25; 95% CI: 1.07─1.47), and condom counselling (OR=1.32; 95% CI: 1.14─1.53). Qualitative interview participants described how AGYW sought alcohol from older men, knowing that sex would be expected in exchange. This put them in high-risk situations where sexual violence was a concern and negotiating condom use became more challenging. These findings highlight the need for interventions that educate AGYW on the harmful effects of binge drinking and provide safer, healthier alternatives for recreation, particularly in low-resourced communities.

Introduction Adolescence is a time of rapid physical, social and psychological development and many risk factors for mental disorders have their roots in this age period. Primary prevention through school platforms has been extensively used and evaluated, but many interventions have poor uptake, high dropout and limited long-term sustainability. Mental health is a complex phenomenon and may be best supported through multicomponent interventions that more holistically consider inner, social and environmental levels. Character education-focused interventions are effective for improving adolescent psychosocial functioning and mental well-being. Therefore, an intervention that focuses on developing these strengths and is delivered within a school environment, through an adolescent-informed approach using creativity-focused components, has the potential to improve adolescent mental health and well-being. Methods and analysis This protocol describes the YiPEE cluster-randomised controlled trial with concurrent mixed-methods process evaluation and economic evaluation, which aims to determine the impact of a multilevel multicomponent intervention in schools in Chennai, Tamil Nadu, India. Clusters—defined as schools which include Grades 6–8 (ages 11–16 years), will be randomised to intervention (n=15) or control (n=15). The intervention consists of: an 8-week classroom-based component, a 12-week teacher-focused component and a board comprising members from across the whole school. All children attending Grade 7 (aged 12–15) will be exposed to the classroom component, and teachers who actively teach Grade 7 will be invited to participate in the teacher component. Within schools, students for the individual-level evaluation will be included if they are: (1) aged 12–15 years; (2) currently attending Grade 7; (3) competent to give consent and (4) have a legal guardian competent of giving consent. We aim to sample a minimum of 100 students from each school (n=3000). All teachers of Grades 6–8 will be recruited for the evaluation. The primary outcome is symptoms of anxiety and depression measured using an abbreviated version of the UNICEF MMAPP tool. The primary analysis will be intention-to-treat, comparing the mean change in mental health score between baseline and endline, between intervention and control clusters. In addition, we will record school monitoring data (student attendance, student grades). Individual interviews with students and teachers, focus group discussions with school staff, and ethnographic observations will provide data for the process evaluation. For the economic evaluation, the combined direct and non-direct costs will be compared with changes in mental health in the intervention arm. Ethics and dissemination The trial is approved by the Ethics Council of the Schizophrenia Research Foundation, India, with approval number EC/NEW/INST/2023/TN/0329. We plan to publish the main impact, process and economic evaluation results as academic publications in international peer-reviewed journals in 2026. Trial registration number Clinical Trials Registry—India (CTRI/2024/07/070949).

Objective: To investigate the perceived healthfulness, nutrient content awareness, consumption, and intention to purchase selected ultraprocessed products (UPP) and their sociodemographic determinants. Design: Cross‐sectional study involving secondary data analysis. Setting: This study was conducted in all nine provinces of South Africa. Participants: In total, 1951 adults (18–50 years), with 63.5% females and 66.3% from low socioeconomic group. Methods: Participants were shown A4 images of mock‐branded UPP, with no nutrition information provided. Questions asked were based on the images to determine the nutrient content awareness, healthfulness perception, consumption frequency, and intention to purchase the UPP based on sociodemographic characteristics. Analysis: Descriptive statistics were conducted for nutrient content awareness, perceived healthfulness, consumption, and intention to purchase UPP. Associations with sociodemographic variables were determined using regression analyses: logistic regression for perceived healthfulness and nutrient content awareness, ordinary least square regression for UPP consumption, and intention to purchase was modeled as a latent variable in a multiple indicators multiple cause (MIMIC) model. Results: Over a third of participants (41.8%) were not aware that fruit juice is high in sugar. Only 13% of the participants perceived fruit juice as unhealthy and more than 50% showed the intention to purchase fruit juice, cereals, and yoghurt in the future. More than 50% reported consuming most UPP either daily or weekly. Perceived healthfulness was associated with gender, while UPP consumption was associated with education, age, gender, and being unemployed. Intention to purchase UPP was the only variable associated with socioeconomic status. Conclusion and Implications: Intervention strategies such as simplified front‐of‐pack labeling may have a role in improving nutrition awareness and discouraging UPP consumption.

Background: Anthropometric data quality in large multicentre nutrition surveys is seldom adequately assessed. In preparation for the South African National Dietary Intake Survey (NDIS-2022), this study assessed site leads’ and fieldworkers’ intra- and inter-rater reliability for measuring weight, length/height, mid-upper arm circumference (MUAC), waist circumference (WC) and calf circumference (CC). Methods: Standardised training materials and measurement protocols were developed, and new anthropometric equipment was procured. Following two training rounds (12 site lead teams, 46 fieldworker teams), measurement reliability was assessed for both groups, using repeated measurements of volunteers similar to the survey target population. Reliability was statistically assessed using the technical error of measurement (TEM), relative TEM (%TEM), intra-class correlation coefficient (ICC) and coefficient of reliability (R). Agreement was visualised with Bland-Altman analysis. Results: By %TEM, the best reliability was achieved for weight (%TEM = 0.260–0.923) and length/height (%TEM = 0.434–0.855), and the poorest for MUAC by fieldworkers (%TEM = 2.592–3.199) and WC (%TEM = 2.353–2.945). Whole-sample ICC and R were excellent ( > 0.90) for all parameters except site leads’ CC inter-rater reliability (ICC = 0.896, R = 0.889) and fieldworkers’ inter-rater reliability for MUAC in children under two (ICC = 0.851, R = 0.881). Bland-Altman analysis revealed no significant bias except in fieldworkers’ intra-rater reliability of length/height measurement in adolescents/adults ( + 0.220 (0.042, 0.400) cm). Reliability was higher for site leads vs. fieldworkers, for intra-rater vs. inter-rater assessment, and for weight and length/height vs. circumference measurements. Conclusion: NDIS-2022 site leads and fieldworkers displayed acceptable reliability in performing anthropometric measurements, highlighting the importance of intensive training and standardised measurement protocols. Ongoing reliability assessment during data collection is recommended.

Background: The Kin-Antwerp project aimed at improving the quality of care provided to patients with diabetes in Kinshasa, the Democratic Republic of the Congo in Central Africa, including the digitalisation of routine clinical data to improve patients’ follow-up. We aim to analyse the data of a study population of Kin-Antwerp to characterise their demographic features, assess their achievement of glycemic target over time, and identify groups requiring prioritised attention. Methods: We performed a secondary database analysis of routinely collected information from primary care patients with type 2 diabetes followed from 1991 to 2019. Data included demographics (age, sex), anthropometrics (weight, height), clinical parameters (blood pressure, plasma glucose), and anti-diabetic treatments. Achievement of glycemic target, defined as fasting plasma glucose < 126 mg/dL, over time was assessed using a multilevel mixed-effects logistic regression model. Results: Our study population of patients with type 2 diabetes (N = 8976) comprised a higher proportion of women (67%) and patients between 40 and 65 years old (70.4%). At the first follow-up, most patients were on treatment with insulin (56.5%) and had glycemic levels under the target (79.9%). Women presented more often with obesity (27.4%) and high systolic blood pressure (41.8%) than men (8.6% and 37.0%, respectively). Patients had a median follow-up of 1.8 (interquartile range: 0.5–3.4) years. Overall, the odds of achieving glycemic target increased by 18.4% (odds ratio: 1.184, 95% CI: 1.130 to 1.239; p < 0.001) per year of follow-up. Stratified analyses suggested that the odds of achieving glycemic control over time increased among older patients (> 40 years), but not among younger patients (< 40 years). Conclusion: In our study population, an overall poor glycemic control was observed albeit with a modest improvement in the achievement of glycemic target throughout patients’ follow-up. Younger patients may benefit from prioritised attention to achieve glycemic targets. Based on the information provided by the database, continue monitoring and improvement of the project Kin-Antwerp is recommended. Introducing further efforts to improve type 2 diabetes management should include robust glycemia-monitoring tools and haemoglobin A1c, as well as further outlining self-management strategies.

This study aims to compare trends in antibiotic prescribing behaviour for lower urinary tract infections among different out-of-hours primary care services.Cross-sectional study using routine presc...

In 2014–2015, we conducted a randomized controlled trial (RCT) assessing the effect of an advertising campaign for influenza vaccination using posters and pamphlets in general practitioner (GP) waiting rooms. No effect of the intervention could be demonstrated, but the immunization uptake increased in both arms of the study. In 2019, we deepened the investigations explaining the increased uptake conducting a registry-based 4/2/1 cluster RCT designed by Zelen with two extra years of follow-up of the study cohort. The study population included 23,024 patients eligible to be vaccinated who were registered with 175 GPs. The main outcome remained the number of vaccination units delivered per study group. Data were extracted from the SNIIRAM warehouse claim database for the Lille-Douai district (northern France). No difference in vaccination uptake was found in the Zelen versus the control group of the initial RCT. Overall, the proportion of vaccinated patients increased in the cohort from 51.4% to 70.4% over the three years. Being vaccinated the previous year was a strong predictor of being vaccinated in a subsequent year. The increase in vaccination uptake, especially among people older than 65, can be explained by a cohort effect. Health promotion and the promotion of primary health care may play an important role in this increase.