Interventions supporting engagement with sexual healthcare among people of Black ethnicity: a systematic review of behaviour change techniques

Five interventions aimed to increase STI testing.^{21,23,24,34,35} Harawa et al.²¹ used personalised wellness plans, peer mentors, and group educational and social sessions. There was a significant increase in STI screening in the intervention group (pre, 32%; post, 88%) and the control group (pre, 23%; post, 70%). However, no significant between-group changes occurred. Sánchez et al.³⁵ found no differences in ethnic groups syphilis testing rates at a health event promoting syphilis testing in minorities (Black participants, 33.5%; Hispanic participants, 42.6%; other participants, 48.3%; P = 0.055). Dolcini et al.³⁴ reported a psycho-educational friendship group-based intervention did not significantly increase STI testing compared to a control (37% vs 42.4%). Similarly, Wilton et al.²³ also found no significant increase in STI testing between a psycho-educational group-based intervention and a wait-list control group at 3-month follow-up (42.5 vs 35.5%, OR = 1.47; 95% CI = 0.86–2.51) and 6-month follow-up (33.9% vs 32.3%, OR = 1.17; 95% CI = 0.69–1.98).

Two studies aimed to increase engagement with STI treatment.^22,24 Jones et al.²² reported findings from a contact tracing intervention for chlamydia that was adapted to address barriers to engagement, such as staff availability, method of contact and chlamydia education. After the adaption, participants were significantly more likely to make a treatment plan (RR, 1.14; 95% [CI], 1.01–1.27; P = 0.03) and complete treatment compared with the original intervention (RR, 1.45; 95% [CI], 1.20–1.75; P = 0.0001). Partners of participants were also significantly more likely to complete treatment than those in the original intervention (RR, 3.02; 95% [CI], 1.81–5.05; P = 0.0001).²² Wingood et al.²⁴ reported participants in a psycho-educational intervention for women were more likely to communicate STI results to concurrent male sexual partners (OR = 1.52; 95% CI = 1.11–2.06), and their partners were more likely to complete treatment for STIs (OR = 1.41; 95% CI = 1.05–1.90) than those in the control group.

Eleven further studies aimed to increase testing for HIV.^{18–22,24,32–35,37} Two of these studies delivered HIV information and content related to HIV-related behaviours/attitudes through video interventions. Washington et al.³¹ found participants who received the video intervention via social media were seven times more likely to have tested for HIV at 6-week follow-up than those in a control group (OR = 7.00, 95% CI [1.72, 28.33], P=0.006). However, Chittamuru¹⁸ reported that a 13-episode drama video did not significantly increase HIV testing compared with the control group at 3-month follow-up.

Four studies used group-based interventions to increase HIV testing. Diallo et al.³⁶ reported a single-session HIV prevention workshop significantly increased HIV testing and receipt of test results compared with the control group at 6 months (AOR = 2.30; 95% CI = 1.10, 4.81). Dolcini et al.³⁴ found 14–15-year-olds in a friendship group-based intervention for young people were more likely to have tested for HIV than those in a control group (OR = 7.43, P = 0.05, 95% CI = 0.95–58.33). Dolcini et al.³⁴ suggested different ages may respond differently to intervention content and future interventions should be refined specifically for developmental groups. Frye et al.¹⁹ reported no significant increase in HIV testing at 3 months following a psycho-educational group session (baseline: 62.9%, 3-months: 71.4%; P = 0.63). Similarly, Wilton et al.²³ found no significant group differences in self-reported HIV testing at 3 months for a group-based weekend retreat intervention. However, intervention participants had 81% greater odds of HIV testing at 6 months than comparison participants (OR = 1.81, 95% CI = 1.08–3.01, P = 0.023).

Three studies used community-engagement approaches. Berkley-Patton et al.¹⁷ delivered intervention content through multi-level church outlets, finding that HIV testing increased significantly in both the intervention (23–47%, P = 0.01) and comparison group (19–28%, P = 0.012) at 6 months. However, the intervention group who received culturally tailored content were 2.2 times more likely to have tested for HIV (OR 2.2, 95% CI [0.97–5.10], P = 0.06). Kenya et al.³³ found testing with a community health worker significantly increased home-based rapid HIV testing compared with control participants testing alone (P ≤ 0.05) and significantly increased access to HIV care if positive (100% vs 83%, χ² [1, N = 60] = 5.46, P ≤ 0.02). Seguin et al.³² reported the HIV self-sampling return rate was 55.5% (66/119, 95% CI 46.1%−64.6%) when practice nurses and community workers opportunistically distributed testing kits using a HIV rationale script.

Two studies used peer-mentoring interventions. Harawa et al.²¹ found no significant increase in HIV testing in participants assigned trained peer mentors. However, Frye et al.²⁰ found that friendship pairs who did HIV self-testing together had twice the odds of reporting HIV testing in the past 3 months (OR = 2.29; 95% CI 1.15, 4.58) and almost twice the odds at 6-month follow-up (OR = 1.94; 95% CI 1.00, 3.75). Self-testing was significant at 3-month follow-up (P < 0.02) and marginally significant at 6 months (P ≤ 0.05).

Eight interventions aimed to increase adherence to antiretroviral treatment (ART).^{21,25–30,37} Bouris et al.²⁶ used an intervention group to enhance social support. Intervention participants were 2.91 times more likely to have ≥90% medication adherence (95% CI: 1.10–7.71; P = 0.031) than control participants. Ma et al.²⁹ reported that while at baseline, no participants met the 80% ART adherence criterion, after using an outreach worker to observe participants’ ART intake, 75% met the 80% adherence criterion at 3 months, and 67% met the 80% adherence criterion at 6 months. Pagan-Ortiz et al.³⁷ found SMS adherence reminders with HIV information increased adherence after 8 weeks (baseline, 38%; 8 weeks, 86%). Guy et al.²⁷ found no significant increase in ART adherence in a group-based intervention.

Three studies reported the use of counselling-based interventions to increase ART adherence. Bogart et al.²⁵ found client-centred counselling increased ART adherence compared with the control group (OR = 1.30 per month, 95% CI = 1.12–1.51, P < 0.001), representing a large cumulative effect after 6 months (OR = 4.76, Cohen’s d = 0.86). Jones²⁸ reported ART adherence increased with individual counselling, group sessions and supportive phone calls (baseline, 76%; 1 month, 100%; 3 months, 99.17%). However, the increase was not significant. Magidson et al.³⁰ reported an increase in ART use in the intervention group (baseline, 46.9%; 12-month follow-up, 85.7%) and time-matched control group (baseline, 65.5%; 12-month follow-up, 86.7%). Across both groups, there was a significant increase in the likelihood of being on ART over time (logs odds = 0.71, P = 0.001).

Two interventions aimed to increase sexual health appointment attendance.^26,27 Bouris et al.²⁶ found the intervention group 3.01 times more likely to have had ≥three HIV primary care visits in the past 12 months (95% CI, 1.05–8.69; P = 0.04) than the control group. However, Guy et al.²⁷ reported medical appointment attendance to decrease from pre- to post-intervention by 12.5% (P = 0.39).

A theoretical basis was reported for 10 interventions that aimed to increase STI/HIV testing and access to STI treatment. Six interventions which used theory were found to be effective.^{17,21,23,24,31,36} Berkley-Patton et al.¹⁷ reported applying the Theory of Planned Behaviour³⁸ to increase behavioural beliefs about the importance of HIV testing, change normative beliefs, reduce stigma, and enhance perceived behavioural control. The intervention’s mode of delivery was guided by Social-Ecological Theory.³⁹ Diallo et al.³⁶ reported that their intervention was guided by the Health Belief Model,⁴⁰ Transtheoretical Model⁴¹ and Social Cognitive Theory.⁴² However, how the theories were applied was not specified. Harawa et al.²¹ described group intervention activities as being based on Social Cognitive Theory,⁴³ and the intervention’s peer mentors stemming from Social Impact Theory⁴⁴ and Social Comparison Theory.⁴⁵ Washington et al.³¹ reported their intervention to be informed by the Integrative Model of Behaviour Change,^46,47 targeting HIV knowledge, behavioural beliefs, self-regulation skills and ability, social support, and engagement in self-management behaviour. A combination of Social Cognitive Theory,⁴³ Behavioural Skills Acquisition Model,⁴⁸ Transtheoretical Model of Behaviour Change⁴¹ and the Decisional Balance Model⁴⁹ guided the development of Wilton et al.’s²³ intervention. However, how the theories were implemented was not specified. Similarly, Social Cognitive Theory⁴³ was reported to inform Wingood et al.’s²⁴ intervention content, alongside The Theory of Gender and Power.⁵⁰ Theoretically informed content sought to enhance participants’ attitudes and skills to avoid untreated STIs and educate on gender power imbalances and gender-related HIV prevention strategies.

Four ineffective interventions which aimed to increase STI/HIV testing and access to STI treatment reported behavioural theory. Chittamuru¹⁸ reported Social Cognitive Theory⁴³ to inform intervention content. Similarly, Frye et al.¹⁹ used Social Cognitive Theory⁴³ as a theoretical framework alongside Empowerment Theory,⁵¹ Social Identity Theory⁵² and Rational Choice Theory.⁵³ The AIDS Risk Reduction Model⁵⁴ was reported to guide Dolcini et al.’s³⁴ interventions development. Seguin et al.³² reported that the Capability, Opportunity, Motivation, Behaviour Model⁵⁵ was applied to identify barriers and facilitators to behaviour change.

Five studies reported a theoretical basis to interventions aiming to increase HIV treatment adherence and appointment attendance. Bogart et al.²⁵ reported application of Social-Ecological Theory⁵⁶ to address disparities at multiple levels, and Information-Motivational-Behavioural skills model⁵⁷ to build treatment knowledge and adherence skills, self-efficacy, and motivation. Theories addressing multiple levels were also used by Guy et al.²⁷ who applied Intersectionality, Social-Ecological Model⁵⁶ and Social Cognitive Theory⁴³ to target individual, interpersonal, community and structural factors to health disparities. Bouris et al.²⁶ reported that their intervention was grounded in the Information-Motivation-Behavioural Skills model^57,58 and an adapted Transtheoretical Model⁴¹ to target motivation and social factors by addressing attitudes and beliefs about stigma and HIV-specific support. The PEN-3 model (Persons, Extended family, and Neighbours; Perceptions, Enablers and Nurturers; and Positive, Existential, and Negative behaviours)⁵⁹ was used by Jones²⁸ to place culture at the centre of intervention development. Pagan-Ortiz et al.³⁷ reported the Health Belief Model⁶⁰ and Social Cognitive Theory⁴³ as a theoretical basis to address participants’ perceived susceptibility to illness, positive beliefs and adherence, and self-efficacy.

Ten intervention formats and 10 facilitators were identified in interventions aiming to increase STI/HIV testing and access to STI treatment (Table 3). The most commonly used intervention formats in effective interventions were face-to-face group sessions (n = 5) and individual face-to-face sessions (n = 4). Other effective interventions utilised telephone (n = 3), videos (n = 2), SMS messages (n = 1), resource material (n = 1), posters (n = 1), church bulletins (n = 1), and letters (n = 1).

The most frequently used intervention facilitators in effective interventions were digital (n = 4), peers (n = 3) and printed material (n = 2). The following facilitators were used once: trained facilitators, health educators, church pastors, church health liaisons, screening and treatment program staff, community health worker, community workers and actors.

Six intervention formats and eight facilitators were identified for interventions aiming to increase HIV treatment adherence and appointment attendance (Table 4). The most reported intervention formats in effective interventions were individual face-to-face sessions (n = 3), group face-to-face sessions (n = 2) and booklets (n = 1).

Intervention facilitators used in effective interventions included counsellors (n = 1), social worker interventionist (n = 1), trained therapist (n = 1) and printed material (n = 1).

A total of 26 novel BCTs were identified (Table 5). The number of BCTs within each intervention ranged from two to 13 (mean, 6.6). The most commonly observed BCTs across all interventions aiming to increase STI/HIV testing and access to STI treatment were information about health consequences (n = 13), instruction on how to perform behaviour (n = 9), framing/reframing (n = 7) and demonstration of the behaviour (n = 7).

Within the nine interventions found to significantly increase STI/HIV testing and access to STI treatment within the intervention group, observed BCTs ranged from 2 to 13 (mean, 6). Commonly observed BCTs included information about health consequences (n = 8), instruction on how to perform behaviour (n = 6), information about social and environmental consequences (n = 4), and framing/reframing (n = 4). The following BCTs were solely used in effective interventions: goal setting (behaviour); review behaviour goal(s); information about social and environmental consequences; social comparison, reduce negative emotions; and restructuring the social environment.

Five interventions did not report a significant increase in their intervention group. The BCTs reported within these interventions ranged from 5 to 10 (mean, 7.8). The most observed BCTs were information about health consequences (n = 5) and demonstration of the behaviour (n = 4). Asking individuals to commit to behaviour change was the only BCT used solely in an intervention that did not report a significant increase in their intervention group.

A total of 31 novel BCTs were observed (Table 6). The number of BCTs reported ranged from 4 to 14 (mean, 9.6). The most commonly reported BCTs across all interventions aiming to increase HIV treatment adherence and appointment attendance were problem solving (n = 6), information about health consequences (n = 6), restructuring the social environment (n = 4), information about social and environmental consequences (n = 4), and review behavioural goal(s) (n = 4).

Within three intervention groups found to significantly increase adherence to HIV treatment and appointment attendance, observed BCTs ranged from 8 to 14 (mean, 10). The most frequently used BCT in the effective intervention groups was information about health consequences (n = 3), problem solving (n = 2), information about social and environmental consequences (n = 2), and review behavioural goal(s) (n = 2). The following BCTs were only used once and within effective interventions: discrepancy between current behaviour and goal; review outcome goal(s); behavioural contract; self-monitoring of the behaviour; feedback on outcome(s) of behaviour; habit formation; pros and cons; and non-specific reward.

Four interventions were reported not to be effective, in which the BCTs identified ranged from 4 to 14 (mean, 9.25). The most commonly identified BCTs within these interventions were problem solving (n = 4), information about health consequences (n = 3), goal setting (behaviour) (n = 3), and restructuring the social environment (n = 3). The following BCTs were only used once and within interventions not found to be effective: monitoring of behaviour by others without feedback; monitoring of outcome(s) of behaviour without behaviour; social support (unspecified); social support (practical); demonstration of behaviour, social comparison; pharmacological support; and focus on past success.