Ellen Sogolow

Gender differences for non-fatal unintentional fall related injuries among older adults

Objectives: To quantify gender differences for non-fatal unintentional fall related injuries among US adults age 65 years and older treated in hospital emergency departments (EDs). Methods: The authors analyzed data from a nationally representative sample of ED visits for January 2001 through December 2001, available through the National Electronic Injury Surveillance System All Injury Program (NEISS-AIP). For each initial ED visit, coders record one principal diagnosis (usually the most severe) and one primary part of the body affected. Results: Based on 22 560 cases, an estimated 1.64 million older adults were treated in EDs for unintentional fall injuries. Of these, approximately 1.16 million, or 70.5%, were women. Fractures, contusions/abrasions, and lacerations accounted for more than three quarters of all injuries. Rates for injury diagnoses were generally higher among women, most notably for fractures which were 2.2 times higher than for men. For all parts of the body, women’s injury rates exceeded those of men. Rate ratios were greatest for injuries of the leg/foot (2.3), arm/hand (2.0), and lower trunk (2.0). The hospitalization rate for women was 1.8 times that for men. Conclusions: Among older adults, non-fatal fall related injuries disproportionately affected women. Much is known about effective fall prevention strategies. We need to refine, promote, and implement these interventions. Additional research is needed to tailor interventions for different populations and to determine gender differences in the underlying causes and/or circumstances of falls. This information is vital for developing and implementing targeted fall prevention strategies.

A meta-analysis of the effect of HIV prevention interventions on the sex behaviors of drug users in the United States

Summary: We examined the effectiveness of 33 U.S.‐based HIV intervention studies in reducing the sexual risk behaviors of drug users by reducing unprotected sex or increasing the use of male condoms. The studies, identified as of June 1998, through the HIV/AIDS Prevention Research Synthesis project, were published in 1988 or later, measured behavioral or biologic outcomes, used experimental designs or certain quasiexperimental designs, and reported sufficient data for calculating an effect size for sexual risk reduction. Of the 33 studies, 94% recruited injection drug users; 21% recruited crack users. The mean age of participants was 36 years. Almost all studies were randomized (94%), provided another HIV intervention to the comparison groups (91%), and evaluated behavioral interventions (91%). On average, interventions were conducted in 5 sessions (total, 10 hours) during 4.5 months. Interventions compared with no interventions were strong and significant (k = 3; odds ratio [OR], 0.60; 95% confidence interval [CI], 0.43‐0.85). Interventions compared with other HIV interventions showed a modest additional benefit (k = 30; OR, 0.91; 95% CI, 0.81‐1.03). When we extrapolated our result (an OR of 0.60) to a population with a 72% prevalence of risk behavior, the proportion of drug users who reduced their risk behaviors was 12.6% greater in the intervention groups than in the comparison groups. Our meta‐analysis shows that interventions can lead to sexual risk reduction among drug users and justifies providing interventions to drug users. Developing interventions with stronger effects to further reduce sexual risk behaviors among drug users must remain a high priority.

Meta-analysis of the effects of behavioral HIV prevention interventions on the sexual risk behavior of sexually experienced adolescents in controlled studies in the United States.

Summary: To estimate the effect of behavioral and social interventions on sexual risk of HIV among sexually experienced adolescents in the United States and to assess factors associated with variation in outcomes, we selected studies from the HIV/AIDS Prevention Research Synthesis project database. Twenty studies published or reported during the years 1988 through 1998 met criteria: 16 presented sufficient data; of these, 15 evaluated behavioral interventions and 1 a social intervention. Summary odds ratios (ORs) and 95% confidence intervals (CIs), weighted by study precision, indicated significantly less sex without condoms (number of studies, k, 13; OR, 0.66; CI, 0.55 0.79) and lower behavioral risk (k, 2; OR, 0.66; CI, 0.50‐0.88), but no difference in number of partners (k, 8; OR, 0.89; CI, 0.76‐1.05) or STDs (k, 2; OR, 1.18; CI, 0.48‐2.86). A composite sexual risk behavior variable (k, 16; 1 outcome per study; preferred order, sex without condoms, number of partners, risk index) was used for heterogeneity and publication bias tests and stratified analyses. Overall, these interventions had a significant protective effect on sexually experienced adolescents (k, 16; OR, 0.65; CI, 0.50 ‐ 0.85), although there was a suggestion of publication bias. Study design and intervention variables did not explain outcome variation. An exploratory finding may merit investigation: interventions tested with single ethnic groups out‐ofclass (k, 5) had larger effects than in‐class interventions with mixed ethnic groups (k, 11), whether the mixed groups were in‐ (k, 6) or out‐of class (k, 5).

HIV Prevention Research for Men Who Have Sex with Men: A Systematic Review and Meta-analysis

Summary: A systematic review of HIV prevention reports published or distributed in the United States as of June 1998 yielded 9 rigorous controlled trials reporting intervention effects on unprotected sex for men who have sex with men. A summary measure of these effects was favorable (odds ratio, .69), statistically significant (95% confidence interval, 0.56‐0.86), and very homogeneous. This summary value indicates a 26% reduction in the proportion of men engaging in unprotected anal intercourse. The most clearly favorable effects were observed among interventions that promoted interpersonal skills, were delivered in community‐level formats, or focused on younger populations or those at higher behavioral risk. These studies demonstrate that interventions can promote risk reduction among men who have sex with men. Yet given the epidemiology of HIV in the United States, the small number of rigorous controlled intervention trials for this population is striking. Many more rigorous evaluations of HIV prevention efforts with men who have sex with men are needed to ascertain with confidence the effects of specific intervention components, population characteristics, and methodologic features.

Review and meta-analysis of HIV prevention intervention research for heterosexual adult populations in the United States

Summary: A meta‐analysis was performed to examine the effects of 14 behavioral and social interventions for heterosexual adults on their adoption of safer sex behaviors or incidence of sexually transmitted diseases (STDs). The intervention studies were identified through a systematic search and review strategy. Data were extracted and combined by using well‐defined methods and appropriate statistical techniques. For inclusion in this article, studies had to be based in the United States, written in English, first reported between 1988 and 1996, and aimed at reducing sex‐related HIV risks. In addition to measuring behavioral or STD incidence outcomes, studies also had used experimental or quasi‐experimental designs with control or comparison groups and reported sufficient outcome data to allow calculation of odds ratios. The meta‐analytic results show statistically significant effects in reducing sex‐related risks (10 studies; odds ratio [OR], 0.81; 95% confidence interval [CI], 0.69‐0.95), particularly non‐use of condoms (8; OR, 0.69; 95% CI, 0.53‐0.90). The interventions also had significant effects in reducing STD infections (6 studies; OR, 0.74; 95% CI, 0.62‐0.89). These analyses indicate that science‐based prevention interventions have positive effects among populations at risk through heterosexual transmission and that these positive effects are found with biologic and self‐reported behavioral measures.

A profile of U.S.-based trials of behavioral and social interventions for HIV risk reduction.

Summary: We describe 99 (experimental and certain quasi‐experimental) U.S.‐based trials, reported or published since 1988, of behavioral and social interventions that measured prespecified behavioral and biologic outcomes and aimed to reduce risk for HIV infection. Studies identified through June 1998 by the HIV/AIDS Prevention Research Synthesis project were grouped into 4 risk behavior areas: drug‐related (k [number of studies] = 48), heterosexual youth (k = 24), heterosexual adult (k = 17), and same‐sex (k = 10). We compared the studies in the 4 areas by variables key to the development, evaluation, and transfer of interventions. Participants comprised injection drug users (43% of studies), drug users out of treatment (29%), African Americans (18%), clinic patients (18%), youth in schools (10%), and drug users in treatment (10%). Most studies were randomized (85%), provided another intervention to the control or comparison groups (71%), and evaluated behavioral interventions (92%). On average, interventions were conducted in 5 sessions (total, 8 hours) during 3 months. The theoretical basis of the intervention was not noted in 57% of the reports. At least one variable from each of the 3 outcome classifications was measured in 8% of the studies: behavioral, biologic, and psychosocial. Distinct profiles exist for the 4 risk areas. Addressing gaps in research and reporting would be helpful for analytical and program activities. This sizable portfolio of evaluated interventions contributes to effectiveness reviews and to considerations of transfer to program practice.

A protocol for the analytical aspects of a systematic review of HIV prevention research.

Summary: Quantitative analysis can reveal the consistency of intervention effects across studies, as well as the variation of effects according to study‐level characteristics. After consulting with project experts in methods and content, and reviewing the literatures on research synthesis and on HIV prevention, we developed a systematic protocol of analytical methods for synthesis of behavioral and biologic outcome data from HIV intervention studies. This protocol included procedures for identifying eligible studies; defining, characterizing, and prioritizing outcomes; abstracting and calculating estimates of effect; adjusting for baseline distributions and intraclass correlation; transforming estimates to a common metric; summarizing effects; examining differences in effectiveness among groups of studies; and translating these results into terms useful to HIV prevention practitioners and researchers. We applied these procedures to transform outcome data reported in many different statistical formats into odds ratios that could be combined and compared across studies. We analyzed data on behaviors related to sexual risk for HIV infection (unprotected sex, condom use, and number of partners) as well as data on biologic outcomes (incidence of HIV and other sexually transmitted infections). This framework may be useful for meta‐analyses of prevention research in other fields, particularly when primary research features diverse outcome measures and methods of analysis.

The HIV/AIDS Prevention Research Synthesis Project: Scope, Methods, and Study Classification Results

Summary: In 1996, the Centers for Disease Control and Prevention (CDC), in collaboration with many partners, initiated the HIV/AIDS Prevention Research Synthesis (PRS) project to accumulate HIV prevention research studies and analyze their effectiveness in reducing sexual and drug‐related risk behaviors for HIV transmission. The PRS team developed standardized guidelines and procedures for the systematic reviews, conducted systematic searches for pertinent studies, characterized the selected studies, analyzed effectiveness data, and established a cumulative database. As of June 1998, the database contained more than 5000 reports: 4068 were reports that met the PRS scope criteria for inclusion and 586 of those reports contained outcome data from an intervention study. Of the 586 reports that included outcome data, 276 have been reviewed: 223 (81%) included measures of PRS‐specified behavioral or biologic HIVrelated outcomes, and 124 of the 223 (56%) used PRS‐defined rigorous study designs. The PRS database is a valuable resource for accessing and integrating the literature on HIV prevention research. CDC is committed to 1) updating the database; 2) producing systematic reviews, including meta‐analyses, related to key research questions; and 3) disseminating findings to encourage and facilitate the use of science‐based research in preventing HIV infection.

Theoretical issues in the synthesis of HIV prevention research.

Summary: The evidence base for science and health policy consists of many independent research studies. Combining evidence from multiple studies that differ in important ways presents challenges that have been addressed in other areas of scientific research and are now beginning to be addressed in HIV prevention research. Syntheses can enhance statistical power and produce summary evidence that is more generalizable than individual primary research.

The role of supervision of children in injury prevention

The findings and conclusions in this commentary are those of the authors and do not necessarily represent the views of CDC.(1) National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, Centers for Disease Control and Prevention, USA.(2) Westat, USA.Address reprint requests to: Karin Mack. CDC/NCIPC/DUIP/H&R, 4770 Buford Hwy., NE, MS F62, Atlanta, GA 30341.E-mail: kmack@cdc.gov