Cost-effective way to reduce stimulant-abuse among gay/bisexual men and transgender women: a randomized clinical trial with a cost comparison

OBJECTIVES

A randomized controlled study was conducted with 422 homeless, stimulant-using gay/bisexual (G/B) men and 29 transgender women (n = 451) to assess two community-based interventions to reduce substance abuse and improve health: (a) a nurse case-managed program combined with contingency management (NCM + CM) versus (b) standard education plus contingency management (SE + CM).

STUDY DESIGN

Hypotheses tested included: a) completion of hepatitis A/B vaccination series; b) reduction in stimulant use; and c) reduction in number of sexual partners.

METHODS

A deconstructive cost analysis approach was utilized to capture direct costs associated with the delivery of both interventions. Based on an analysis of activity logs and staff interviews, specific activities and the time required to complete each were analyzed as follows: a) NCM + CM only; b) SE + CM only; c) time to administer/record vaccines; and d) time to receive and record CM visits. Cost comparison of the interventions included only staffing costs and direct cash expenditures.

RESULTS

The study outcomes showed significant over time reductions in all measures of drug use and multiple sex partners, compared to baseline, although no significant between-group differences were detected. Cost analysis favored the simpler SE + CM intervention over the more labor-intensive NCM + CM approach. Because of the high levels of staffing required for the NCM relative to SE, costs associated with it were significantly higher.

CONCLUSIONS

Findings suggest that while both intervention strategies were equally effective in achieving desired health outcomes, the brief SE + CM appeared less expensive to deliver.

A randomized controlled trial of two treatment programs for homeless adults with latent tuberculosis infection

SETTING

Few studies have examined strategies for optimizing adherence to latent tuberculosis infection (LTBI) treatment programs in homeless populations.

OBJECTIVES

1) To compare the effectiveness of an intervention program employing nurse case management and incentives (NCMI) vs. a control program with standard care and incentives on completion of LTBI treatment; and 2) to compare the impact of the two programs on tuberculosis (TB) knowledge among participants.

DESIGN

A prospective, two-group site-randomized design conducted among 520 homeless adults residing in the Skid Row region of Los Angeles from 1998 to 2003, assessing completion rates of a 6-month isoniazid (INH) treatment program and change in TB knowledge.

RESULTS

Using intent-to-treat analysis, 62% of participants in the intervention program, compared with 39% of controls, completed the full 6-month course of LTBI treatment with INH. Logistic regression modeling revealed that intervention participants had three times greater odds of completing INH treatment than controls. TB knowledge improved in both programs, but the increase was greater among the intervention participants (P < 0.001).

CONCLUSIONS

Nurse case management combined with education, incentives, and tracking dramatically improves both adherence to LTBI treatment and TB knowledge in homeless persons compared to a standard approach of outreach and incentives.

Collaborative inquiry with low-income Latina women

Collaborative inquiry is a form of research in which researchers and participants work collaboratively as partners. The purpose of this paper is to demonstrate the process of collaborative inquiry through an example of a longitudinal, community-based study conducted over a six-year period. The research program focused on HIV education, counseling, and antibody testing with low-income Latina women attending a nutrition program for women, infants, and children (WIC) in Los Angeles. Collaborative, community-based inquiry emerges from the community and uses members of the targeted group to design the program, convey the message, act as advocates, evaluate the outcomes of the program, and disseminate research findings. The goal is empowerment and emancipation of both participants and researchers. Five areas in the conduct of community-based collaborative inquiry are demonstrated here: program design, implementation, evaluation, dissemination of the results of the program, and empowerment and emancipation.

Sheltered versus nonsheltered homeless women differences in health, behavior, victimization, and utilization of care

OBJECTIVE

To contrast sociodemographic characteristics, physical and mental health status, substance use, sexual behaviors, victimization, and utilization of health services between homeless women residing in sheltered and non-sheltered environments.

DESIGN

Cross-sectional survey. A structured scale was used to measure mental health status. Physical health status, substance use, sexual behavior, history of adult victimization, and health services utilization were measured by content-specific items.

SETTING

Shelters (N = 47) and outdoor locations in Los Angeles.

PARTICIPANTS

One thousand fifty-one homeless women.

RESULTS

Homeless women living on the streets were more likely than sheltered women to be white and longer-term homeless. Controlling for sociodemographic characteristics, multiple logistic regression analyses revealed that unsheltered women had over 3 times greater odds of fair or poor physical health, and over 12 times greater odds of poor mental health than sheltered homeless women. They were also more likely than sheltered women to report using alcohol or noninjection drugs, to have multiple sexual partners, and to have a history of physical assault. About half of the overall sample reported utilization of a variety of health services; however, unsheltered homeless women were less likely to utilize all of the health services that were assessed, including drug treatment.

CONCLUSIONS

There is a critical need for aggressive outreach programs that provide mental health services and substance abuse treatment for homeless women on the streets. Comprehensive services that also include medical care, family planning, violence prevention, and behavioral risk reduction may be particularly valuable for homeless women, especially those living in unsheltered environments.

Attaining gender and ethnic diversity in health intervention research: cultural responsiveness versus resource provision

Despite the National Institutes of Health (NIH) mandate to include women and diverse ethnic groups in all NIH-funded research projects, these groups are still excluded as participants in health intervention research. This exclusion has denied them access to state-of-the-art treatments and prevention strategies. making them vulnerable to increased morbidity and mortality and decreased longevity. This article compares two conceptual approaches to inclusion: cultural responsiveness and resource provision. Several issues are raised as to why women and ethnic people of color are not involved in health intervention research. For each of these issues, an appraisal is made as to whether cultural responsiveness or resource provision would more successfully address the problem. It is concluded that cultural responsiveness facilitates participation in research but is not sufficient. An equally important, if not more important, approach may be the provision of resources to empower participants to address problems of access and burden.

Personal, cognitive, behavioral, and demographic predictors of HIV testing and STDs in homeless women

Using a multiracial sample of 621 homeless women, we tested a latent variable causal model of personal, cognitive, behavioral, and demographic predictors of two coping mediators and the outcome variables of HIV testing and return for test results and a recent STD infection. HIV testing and return were predicted by more social support, greater AIDS knowledge, greater perceived risk for AIDS, and more problem-focused coping strategies. Recent STDs were predicted by more AIDS knowledge, emotion-focused coping strategies, and risky sexual behavior and one measured variable, crack cocaine use. Emotion-focused coping strategies were predicted by drug use, less self-esteem, more social support, and greater perceived risk for AIDS. Hispanics reported less emotion-focused coping strategies than African-Americans. Predictors of problem-focused coping strategies included less drug use, more self-esteem, more social support, more AIDS knowledge, and less risky sexual behavior. African-Americans reported less problem-focused coping strategies than Latinas. Indirect effects on the outcomes mediated through coping styles are also reported. Theoretical and practical implications of results for community outreach are discussed.

Psychosocial predictors of current drug use, drug problems, and physical drug dependence in homeless women

We examined risk and protective factors associated with three qualitatively different drug use constructs describing a continuum of drug use among a sample of 1,179 homeless women. Relationships among positive and negative sources of social support, positive and negative coping strategies, depression, and the drug constructs of current drug use, drug problems, and physical drug dependence were assessed using structural equation models with latent variables. Current drug use was predicted by more negative social support (from drug-using family/friends), depression, and less positive coping. Drug Problems were predicted by more negative coping, depression, and less positive coping. Physical Drug Dependence was predicted by more negative social support and depression, and less positive social support. Results highlighted the importance of investigating both the positive and negative dimensions of psychosocial functioning, while suggesting that empowering homeless women and offering tangible resources for coping with the stress of being homeless may be beneficial to them.

Two-year follow-up of AIDS education programs for impoverished women

The long-term effects of two culturally competent AIDS education programs with different content on the risk behavior and AIDS-related knowledge of 410 homeless African American women 2 years after program completion were examined. Participants were members of a larger cohort of impoverished African American and Latina women recruited in Los Angeles from 1989 to 1991. Of a subsample of 527 African American women selected randomly for a 2-year follow-up interview, 410 (78%) were located and agreed to participate. Women participating in both AIDS education programs reported reduced HIV risk behaviors and demonstrated greatly improved AIDS knowledge at 2-year follow-up (p < .001). Women in a specialized program were less likely than those in a traditional program to report noninjection drug use at 2 years. Women in the traditional program had significantly better AIDS knowledge at follow-up (p < .001). These findings suggest that educational programs can produce sustained benefits among impoverished women.

Assessing the impact of HIV risk reduction counseling in impoverished African American women: a structural equations approach

We assessed changes in cognitive, psychological, and risky behavior latent variables after traditional or specialized AIDS education after 2 years using structural equation modeling (SEM) in a sample of impoverished at-risk African American women (N = 300). Both groups reported significant improvement at 2 years in their self-esteem and social resources. They also reported less threat perception, avoidant coping, emotional disturbance, HIV risk behavior, and drug use behavior. There was an advantage to specialized group membership. When compared with the traditional group at 2 years, women in the specialized group reported enhanced social resources, reduced emotional distress, less use of an avoidant coping style, and less drug use. We discuss advantages of culturally sensitive HIV risk reduction programs and the importance of connecting women with social services in their communities.

Longitudinal effects of an HIV testing and counseling programme for low-income Latina women

OBJECTIVES

The purpose of this study was to assess the effects of an HIV antibody testing, counseling and education programme on the knowledge and practices of low-income Los Angeles Latina women.

METHODS

The study design was prospective and longitudinal involving pre-test, post-test and retest measures over a 2-year period. The study employed an experimental group and a comparison group which did not receive the intervention. The study group was comprised of a convenience sample of 508 low-income Latina women who were recruited from the Public Health Service nutrition programme for women, infants and children (WIC). The comparison group (n = 51) was recruited from the same setting. A battery of instruments was selected to measure HIV knowledge and practices, the social support received, self-esteem, the level of acculturation and sociodemographic characteristics. The instruments were administered at pre-test, 2 weeks post-test and 1 year retest. The HIV antibody serostatus was assessed at pre-test and retest. An intervention protocol based on cultural competence, women as traditional health care givers and the major transmission categories was provided after the pre-test and was reinforced post-test. Finally, qualitative data were collected from the focus group participants (n = 55) to evaluate the intervention protocol.

RESULTS

The participants in the study made significant improvements in HIV knowledge and reported condom use practices from pre-test to post-test that were retained on retest. The comparison group subjects did not make significant pre-test-post-test improvements on these measures.

CONCLUSIONS

It should be noted that the changes in practices made by the study group did not necessarily reduce their risk of HIV infection or transmission and were not related to the demonstrated knowledge and skills improvement. Of special significance to programme planners, educators and researchers, both the quantitative and qualitative data revealed problem areas with the intervention protocol related to cultural norms and the possible fragmentation of information based on the behavioral transmission categories.

Home medication injection among Latina women in Los Angeles: implications for health education and prevention

Reuse of needles and syringes after home injection of medications and vitamins may be a risk for transmission of HIV. An exploratory study was done to determine (1) how commonly injectable medications were used in the home; (2) whether needles and syringes were reused; and (3) common practices for cleaning needles and syringes. A survey was conducted of low income Latina women (n = 216) who were attending a Public Health Foundation nutrition programme for women, infants and children (WIC) in Los Angeles. To clarify and expand on the survey findings, focus group interviews were done with an additional 55 women attending WIC. Quantitative data were analysed using descriptive and comparative statistics. Qualitative data were subjected to content analysis. The use of injectable medications purchased in Mexico was fairly common (43.5%); reuse of disposable needles and syringes (48%) and sharing (36%) among injectors were also common. Methods of cleaning needles and syringes were inadequate to CDC recommended guidelines. Injectors and non-injectors differed significantly in ethnicity, religion, and marital status. The only significant predictor of medication injection was educational level. Analysis of qualitative data revealed the reasons that Latina subjects were injecting medication; how they were transporting medicines from Mexico; and how they were cleaning their equipment. The practical implications for health education and prevention programmes should include an awareness that home use and reuse of needles for injection of medications may be common in some social groups and that knowledge of the potential dangers in reuse and sharing of needles may not extend to home medication injection.

Predictors of maintained high-risk behaviors among impoverished women

The researchers sought to explore and describe the demographic, cognitive, psychosocial, and behavioral factors associated with the continued risky behavior of a convenience sample of homeless and drug-addicted women two to four weeks after they had completed an AIDS education program. The sample included 942 crack users and 767 women who had multiple sex partners. Analyses revealed that impoverished women who maintained multiple sexual partners were less likely to be in drug recovery programs than in homeless shelters. They were more likely to share needles and be involved sexually with male injection drug users compared with impoverished women who did not maintain multiple sexual partners. Persistent crack users were older than those who reported cessation of crack use, were more often African American, and were more likely to have sex partners who were injecting drug users. Women who demonstrated less improvement in depression and distress scores, concerns, use of affective coping, appraisal of threat, and social support were more likely to maintain crack use and multiple partners. The study's implications for the design of intervention programs aimed at risk reduction based on ethnicity are discussed.

Barriers to condom use and needle cleaning among impoverished minority female injection drug users and partners of injection drug users

This study was undertaken to describe sexual behaviors and drug use and other factors that inhibit condom use and needle cleaning among impoverished women who are injection drug users (IDUs) or sexual partners of IDUs. This study also investigated whether risky sexual behavior or barriers to risk reduction differ with ethnicity and level of acculturation. Survey instruments to assess drug and sexual activity were administered to 378 African American and Latina women recruited primarily from homeless shelters and drug recovery programs. The most commonly cited barriers to condom use were belief that partners did not have acquired immunodeficiency syndrome (AIDS), lack of knowledge about where to get and how to use condoms, and discomfort discussing condom use with partners. African American women were more likely to report having multiple partners and unprotected sex, and more likely to report barriers in using, discussing, and obtaining condoms. Latina women were more likely to report partners' dislike of condoms. African American and highly acculturated Latina women were more likely to be IDUs than less acculturated Latina women. The most pervasive barriers for needle cleaning were not having personal needles, being high and not interested in needle cleaning, and not having disinfectant available. In a multiple logistic regression analysis for engaging in unprotected sex and cleaning needles, not ethnic or acculturation differences were found after controlling for selected demographic characteristics and risk factors. The data indicate a need to increase the supply of free or low cost condoms, to provide easily accessible sites for obtaining condoms, to supply clean needles,and to focus counseling for women on negotiating condom use with partners and the skillful and correct placement of the condom.

Evaluation of two AIDS education programs for impoverished Latina women

This paper evaluates and contrasts the effectiveness of two culturally sensitive AIDS education programs developed by the UCLA AIDS Nursing Network and delivered to 213 impoverished Latina homeless or drug-addicted women in Los Angeles. The Comprehensive Health Seeking and Coping Paradigm guided the program, which was implemented by specially trained Latina nurses and outreach workers. A quasi-experimental design was employed where women were randomized by site into Specialized (N = 82) and Traditional (N = 131) programs. Repeated measures ANOVAS and log-linear models were used to evaluate improvement over a two-week period for women in both groups and to identify interactions with program type. Two-week posttest analyses were also conducted to assess program effectiveness, controlling for baseline values of the measure in question, nonequivalency between groups at baseline, and selected demographic characteristics, including acculturation. Results indicated that women in both AIDS education programs improved significantly in cognitive, behavioral, and psychologic outcomes.

Sense of coherence in minority women at risk for HIV infection

It is theorized that persons with strong sense of coherence are likely to define an event as less stressful and be able to manage a problem more successfully than those with weak sense of coherence. The study investigated the relationship among coherence and personal and environmental concerns, appraisal of threat, emotional distress, and high-risk behaviors in minority women at risk for human immunodeficiency (HIV) infection. As predicted, a significant negative relationship was seen between level of coherence and concerns. Moreover, women strong in coherence reported less negative appraisals of threat, less emotional distress, and fewer high-risk behaviors than those with weak coherence. Results of tests of a path model investigating the impact of coherence and appraisal on distress and risk revealed coherence to be significantly and negatively associated with appraisal, distress, and risk, both directly and indirectly through its association with appraisal. The path model accounted for 45% of the variance in distress, 10% of the variance in appraisal, and 4% of risk behavior. Continuing investigation of factors such as coherence that can lessen the seriousness of environmental stressors is imperative as it relates to women at risk for HIV infection.

Outcomes of specialized and traditional AIDS counseling programs for impoverished women of color

The efficacy and differential effects of specialized (S) and traditional (T) AIDS education programs on cognitive, behavioral, and psychological outcomes were investigated. The sample consisted of 858 impoverished African-American and Latina women (S = 448, T = 410). At baseline, women in the traditional group reported significantly higher distress, greater knowledge of AIDS, and less problem-focused coping. Significant improvements over the 2-week intervention interval were found for participants of both AIDS education programs for appraisal of threat, concerns, knowledge, and attitudes about AIDS, emotion-focused coping, number of sexual partners, IV and non-IV drug use, depression, and distress. However, multivariate analysis indicated that the traditional group had slightly better posttest scores on concerns, emotion-focused coping, knowledge of AIDS, and number of partners than the specialized group. The specialized group reported greater use of problem-focused coping. These differences do not detract from the substantial improvement found for both groups, but they do reinforce the conclusion that the specialized program was not more effective than its standard counterpart.

A community-based Inventory of Current Concerns of impoverished homeless and drug-addicted minority women

The purpose of this series of studies was to refine and evaluate the psychometric properties of a measure of the concerns of impoverished minority women who were homeless and/or drug addicted. A comprehensive review of the literature and qualitative focus groups conducted with homeless and drug-addicted minority women were used to refine the inventory of Current Concerns (ICC) (Weisman, Worden, & Sobel, 1980). A 31-item revised Community-Based Inventory of Current Concerns (CICC) was critiqued by measurements and content experts, and content validity was established. The CICC was administered to 978 black and Hispanic women who were residents of drug recovery programs or were homeless and residing in shelters, single room occupancy hotels, or with family or friends. Principal components factor analysis with varimax rotation resulted in a five-factor solution explaining 53% of the variance. These factors were labeled Competency, Personal Instability/Despondency, Survival, Drug-Related, and Parenting Concerns. Alpha reliability coefficient was .90 for the total scale and .79 to .93 for the subscales. Construct validity was demonstrated by moderate correlations (r = .54) between the total CICC and the CES-D. The revised CICC can be used for clinical and research purposes to aid in assessing the concerns of minority impoverished women.

Relationship of resources to emotional distress, somatic complaints, and high-risk behaviors in drug recovery and homeless minority women

In a sample of 581 homeless or drug-abusing minority women, the relationship of self-esteem, sense of coherence, and support availability to emotional distress, somatic complaints, and high-risk behavior were investigated. Findings revealed that women who were high in self-esteem and stronger in sense of coherence reported significantly less emotional distress, and significantly fewer high-risk behaviors. In addition, women who were high in any of the three resources reported lower somatic complaints. Regression analyses revealed that coherence, self-esteem and support availability jointly accounted for 49% of the variance in emotional distress, 10% of the variance in high-risk activities, and 26% of the variance in somatic complaints. Implications for empowering women at risk for HIV infection are discussed.

Stressors and coping strategies of patients with automatic implantable cardioverter defibrillators

This study investigated the stressors of and coping strategies used by patients living with the automatic implantable cardioverter defibrillator. A descriptive study of stress perceptions and coping strategies was conducted with quantitative and qualitative methods. The Lazarus stress and coping paradigm was used as a theoretic framework. Interviews of 20 subjects revealed a mixture of problem-focused and emotion-focused coping strategies in the physical, psychologic, and social areas. The optimistic coping style facilitated coping best. Nursing implications include fostering the use of mixed coping strategies, including optimism, in living with this device.

Effects of an AIDS education program on the knowledge, attitudes and practices of low income black and Latina women

The purpose of this study was to test the effects of an AIDS education program on the knowledge, attitudes and practices of low income black and Latina women. A pretest-posttest nonequivalent control group design was used with a 2-3 month retest of the experimental group. The sample consisted of 506 experimental and 206 control group women who were clients of the Public Health Foundation's Nutrition Program for Women, Infants and Children in Los Angeles County. The program included a slide-tape presentation, and educational and resource brochures in English and Spanish. Knowledge, attitudes, and sexual and drug use practices were measured using a structured questionnaire that was developed in English and Spanish. Content validity and reliability of the questionnaire were established. A 2-way repeated measures ANOVA examined differences in pretest-posttest knowledge, attitudes, and practices for experimental and control groups and for both racial/ethnic groups. The experimental group made significant gains over the control group on pretest-posttest measures of knowledge and attitudes. Both experimental and control groups made significant changes in practice. Changes in knowledge were retained on retest; changes in practices came close to significance on retest. Blacks and Latinas differed on pretest knowledge and attitudes but not practices. Blacks had more knowledge and positive attitudes on pretest. However, posttest improvements for both knowledge and attitudes were greater in Latinas than in blacks. A multiple regression analysis revealed that the best predictors of knowledge, attitudes and practices were racial/ethnic group, education, and religion. It is concluded that a didactic audio visual program can positively affect the knowledge and possibly the practices of participants and that these are retained over time but that changes in attitudes will take further efforts.

Coping and adjustment to illness in the acute myocardial infarction patient

This study examined the coping strategies of acute myocardial infarction (MI) patients one month following discharge from the hospital. Problem- and emotion-focused coping strategies were identified in 30 acute MI patients and correlated with psychologic, social, and physiologic adjustment variables. Individuals who used more problem-focused coping than emotion-focused coping were found to have better social (p less than .005) and psychologic adjustment (p less than .05). Individuals who had more physiologic symptoms were found to have poorer psychologic adjustment. Early identification of those patients at risk for psychosocial distress is paramount to maximize the patient's coping process and prepare the patient psychologically prior to hospital discharge.

Assessing the coping status of spouses of critically ill cardiac patients: a theoretically based approach

Acute cardiovascular disease is an emotionally traumatic event for the patient and family alike. As nurses are concerned with optimizing the health and well-being of patients and families, the nurse's role in assessing coping responses of the spouses is critical for the formulation of appropriate nursing diagnoses and the development of effective interventions. This article describes the spousal coping instrument, which is based on a conceptual model of nursing and is designed to comprehensively assess the coping responses, factors that influence coping, and outcomes of spouses whose partners have suffered an acute cardiac event.

Black and Latina womens' AIDS related knowledge, attitudes, and practices

As part of a larger study designed to provide an AIDS education and prevention program for low-income black and Latina women in Los Angeles County, a pilot study of black (n = 51) and Latina (n = 56) womens' AIDS related knowledge, attitudes and practices was conducted to gather baseline data and to test an instrument that would measure these variables. The factors underlying the instrument were identified and reliability coefficients were determined. The need for changes in the format and administration of the instrument was identified due to nonresponse to some items. There were sociodemographic differences between the two groups of women as well as differences in knowledge and attitudes. In general, black women had more knowledge of AIDS than Latina women and more positive attitudes. Practices did not differ. Both groups denied drug use and multiple sexual partners.

Parents of children in the pediatric intensive care unit: what are their needs?

The concept of total patient care of a critically ill child in the pediatric intensive care unit (PICU) includes the child's parents. A qualitative, descriptive study was performed to determine parental needs as identified by parents of children in the PICU. Using a flexible, semistructured interview guide, we asked parents about individual and parental role needs that existed while their child was in the PICU. Interview transcriptions underwent content analysis. Parental needs were categorized as physical, psychologic, or sociologic in origin. Finer subcategorizations of need areas were identified. The majority of parental needs were psychologic. Subcategories identified most frequently were "visit or stay with the child" and "child-related information." The specific needs most often identified were to be with the child in the PICU and to receive frequent, accurate and truthful information about the child's condition. Identified needs related primarily to the parental role function and the alleviation of parental stress.