Parent-Level Barriers and Facilitators to HPV Vaccine Implementation in Santo Domingo, Dominican Republic

Cervical cancer is the second leading cause of cancer death for women in the Dominican Republic. Vaccination against human papillomavirus (HPV) could reduce mortality from cervical cancer globally by as much as 90%. The purpose of our study was to explore multi-level barriers and facilitators to implementation of a national HPV vaccine program in the Dominican Republic; this article focuses on parent-level barriers and facilitators. In this qualitative study, we conducted six focus groups (N = 64) with parents of school-age children in the Santo Domingo area of the Dominican Republic, representing diverse socioeconomic groups and geographic settings. Thematic content analysis, using inductive and deductive approaches, was done following transcription and translation of audio-recordings from focus group discussions. Among this group of parents in the Santo Domingo area, facilitators to vaccine uptake were favorable attitudes towards vaccines in general and concern about cervical cancer as a health issue. Barriers found were low to moderate knowledge of HPV and cervical cancer, especially in the rural and suburban groups, and cost and lack of public awareness of the vaccine. This study identified key barriers and facilitators to HPV vaccine implementation in the Dominican Republic. Health messaging, incorporating specialist providers as opinion leaders, will need to be tailored to broad audiences with varying levels of information and awareness, anticipating misinformation and concerns, and will need to emphasize HPV vaccine as a method to prevent cancer.

Barriers to Cervical Cancer Screening and Treatment in the Dominican Republic: Perspectives of Focus Group Participants in the Santo Domingo Area

Introduction: Cervical cancer is the second leading cause of cancer death among women in the Dominican Republic, and high rates persist despite existing Pap smear screening programs. The purpose of this study was to explore Dominican women’s knowledge and attitudes regarding human papillomavirus (HPV) and cervical cancer, cervical cancer screening practices, and perceived barriers and facilitators to early detection of cervical cancer. Method: Six focus groups ( N = 64) were conducted in Spanish in urban, suburban, and rural locations, in private and public school settings, community and workplace settings, in or near Santo Domingo, as part of a larger study on barriers and facilitators to HPV vaccine implementation. Audio recordings were transcribed verbatim and translated from Spanish to English. Qualitative data analysis used inductive and deductive approaches. Results: Knowledge regarding HPV and cervical cancer varied across groups, but all agreed there was significant stigma and fear regarding HPV. Most women reported having Pap screening at least yearly. Follow-up of abnormal Pap testing was less consistent, with cost and uncertainty about provider recommendations identified as barriers. Discussion: Broader examination of provider-level and health system barriers and facilitators to cervical cancer prevention in the Dominican Republic is essential, in order to inform interventions to improve the effectiveness of cervical cancer screening and treatment programs and reduce preventable deaths.

Pedagogical Scholarship in Public Health: A Call for Cultivating Learning Communities to Support Evidence-Based Education

Public health education is experiencing record growth and transformation. The current emphasis on learning outcomes necessitates attention to creating and evaluating the best curricula and learning methods for helping public health students develop public health competencies. Schools and programs of public health would benefit from active engagement in pedagogical research and additional platforms to support dissemination and implementation of educational research findings. We reviewed current avenues for sharing public health educational research, curricula, and best teaching practices; we identified useful models from other health professions; and we offered suggestions for how the field of public health education can develop communities of learning devoted to supporting pedagogy. Our goal was to help advance an agenda of innovative evidence-based public health education, enabling schools and programs of public health to evaluate and measure success in meeting the current and future needs of the public health profession.

The Tobacco Technical Assistance Consortium

Cheryl Healton, DrPH, President and CEO of Legacy, and James W. Curran, MD, MPH, Dean, Rollins School of Public Health, Emory University, look back at their collaboration in the Tobacco Technical Assistance Consortium and the significant contributions being made to change social norms through training and technical assistance.

Depictions of tobacco use in 2007 broadcast television programming popular among US youth

OBJECTIVES

To determine the quantity of tobacco use in network television programming popular among US youth and to examine variation in tobacco depictions by TV Parental Guidelines system rating and television network.

DESIGN

A content analysis was conducted of broadcast network television programming popular among youth. Nielsen viewership rating data were used to identify a sample of top-rated television series for youth aged 12 to 17 years during the fall 2007 television season. Depictions of tobacco use per television episode were examined by TV Parental Guidelines rating and television network. χ(2) testing was used to examine differences in proportions of tobacco depictions across television episode ratings and networks.

SETTING

Data collection and analysis were conducted at the American Legacy Foundation (now known as Legacy).

SUBJECTS

Broadcast television viewers in 2007.

MAIN OUTCOME MEASURE

Tobacco use depictions on broadcast television were examined.

RESULTS

Forty percent of television episodes examined had at least 1 depiction of tobacco use. Of these depictions, 89% were of cigarettes. Among episodes rated TV-PG (ie, parental guidance suggested) (N = 73), 50% showed 1 or more incidents of cigarette use, in contrast to 26% of TV-14 (ie, parents strongly cautioned) episodes. The percentage of episodes with any tobacco use depictions was highest on the FOX network (44%; n = 32), followed closely by The CW (CBS-Warner Brothers) (41%; n = 30).

CONCLUSIONS

Substantial tobacco use was observed in television shows popular among youth. It is projected that almost 1 million youth were exposed to tobacco depictions through the programming examined. Tobacco use on television should be a cause for concern, particularly because of the high volume of television viewing among younger audiences.

Increasing youths' exposure to a tobacco prevention media campaign in rural and low-population-density communities

OBJECTIVES

We examined the effectiveness of a program to increase exposure to national "truth" tobacco countermarketing messages among youths in rural and low-population-density communities.

METHODS

A longitudinal survey of 2618 youths aged 12 to 17 years was conducted over 5 months in 8 media markets receiving supplemental advertising and 8 comparison markets receiving less than the national average of "truth" messages.

RESULTS

Confirmed awareness of "truth" increased from 40% to 71% among youths in treatment markets while remaining stable in comparison markets. Over 35% of all youths who were unaware of the campaign at baseline became aware of it as a direct result of the increased advertising. Youths living in rural and low-population-density communities were receptive to the campaign's messages.

CONCLUSIONS

Through purchase of airtime in local broadcast media, the reach of a national tobacco countermarketing campaign was expanded among youths living in rural and low-population-density areas. This strategy of augmenting delivery of nationally broadcast antitobacco ads can serve as a model for leveraging limited tobacco control resources to increase the impact of evidence-based tobacco prevention campaigns.

Youth smoking prevention and tobacco industry revenue

OBJECTIVES

Epidemiological surveys make it clear that youth smoking contributes to both current and future tobacco industry revenue: over 80% of adult smokers reportedly began smoking before age 18. This paper estimates annual and lifetime revenue from youth smoking, and highlights the association between declines in youth smoking and declines in tobacco industry revenue.

MAIN OUTCOME MEASURES

This paper reports the amount of tobacco industry revenue generated by youth smoking at two points in time (1997 and 2002), and describes the distribution of youth generated tobacco income among the major tobacco companies. The authors project the amount of tobacco industry revenue that will be generated by members of two cohorts (the high school senior classes of 1997 and 2002) over the course of their lifetimes.

RESULTS

In 1997, youth consumed 890 million cigarette packs, generating $737 million in annual industry revenue. By 2002, consumption dropped to 541 million packs and revenue increased to nearly $1.2 billion. Fifty eight per cent of youth generated revenue goes to Philip Morris USA, 18% to Lorillard, and 12% to RJ Reynolds. The authors project that, over the course of their lives, the 1997 high school senior class will smoke 12.4 billion packs of cigarettes, generating $27.3 billion in revenue. The 2002 high school senior class is projected to smoke 10.4 billion packs, generating $22.9 billion in revenue over the course of their lives.

CONCLUSIONS

Cigarette price increases from 1997 to 2002 have resulted in greater revenue for the tobacco industry, despite declines in youth smoking prevalence. However, in the absence of further cigarette price increases, declines in youth smoking are projected to lead ultimately to a loss of approximately $4 billion in future tobacco industry revenue from a single high school cohort.

Youth tobacco surveillance--United States, 2001-2002

PROBLEM/CONDITION

Cigarette smoking is the leading preventable cause of death in the United States, accounting for approximately 440,000 deaths each year. The prevalence of cigarette smoking nationwide among high school students (grades 9-12) increased during the 1990s, peaking during 1996-1997, and then declined. Approximately 80% of tobacco users initiate use before age 18 years. An estimated 6.4 million children aged <18 years who are living today will die prematurely as adults because they began to smoke cigarettes during adolescence. The annual health-related economic cost associated with tobacco use exceeds 167 billion dollars. Because of these health and economic consequences, CDC has recommended that states establish and maintain comprehensive tobacco-control programs to reduce tobacco use among youth.

REPORTING PERIOD

This report covers data collected during January 2001-December 2002.

DESCRIPTION OF THE SYSTEM

The National Youth Tobacco Survey (NYTS) and state youth tobacco surveys (YTS) were developed to provide states with data to support the design, implementation, and evaluation of comprehensive tobacco-control programs. NYTS is representative of middle and high school students in the 50 states and the District of Columbia. During spring 2002, a total of 26,149 students in 246 schools completed NYTS questionnaires. Weighted data for the YTS were achieved by 13 states in 2001 and by 20 states in 2002; state sample sizes varied (range: 982-38,934). This report summarizes data from the 2002 NYTS and the 2001 and 2002 YTS.

RESULTS AND INTERPRETATION

Findings from the 2002 NYTS indicate that current use of any tobacco product ranged from 13.3% among middle school students to 28.2% among high school students. Cigarette smoking was the most prevalent form of tobacco use, with 9.8% of middle school students and 22.5% of high school students reporting that they currently smoke cigarettes. Cigar smoking was the second most prevalent form of tobacco use, with 6.0% of middle school students and 11.6% of high school students reporting that they currently smoke cigars. Among current cigarette smokers, 41.8% of middle school students and 52.0% of high school students reported that they usually smoke Marlboro cigarettes. Black middle school and high school students who smoke were more likely to smoke Newport cigarettes than any other brand (58.3% and 66.8%, respectively). Among middle school students aged <18 years, 75.9% were not asked to show proof of age when they bought or tried to buy cigarettes, and 63.4% were not refused purchase because of their age. Among high school students aged <18 years, 58.5% were not asked to show proof of age when they bought or tried to buy cigarettes, and 60.6% were not refused purchase because of their age. Nearly half (49.6%) of middle school students and 62.1% of high school students who smoke reported a desire to stop smoking cigarettes, with 55.4% of middle school students and 53.1% of high school students reported having made at least one cessation attempt during the 12 months preceding the survey. Among students who have never smoked cigarettes, 21.3% of middle school students and 22.9% of high school students were susceptible to initiating cigarette smoking in the next year. Exposure to secondhand smoke (i.e., environmental tobacco smoke) was high. During the week before the survey, 1) 88.3% of middle school students and 91.4% of high school students who currently smoke cigarettes and 47.1% of middle school students and 53.3% of high school students who have never smoked cigarettes were in the same room with someone who was smoking cigarettes; 2) 81.7% of middle school students and 83.7% of high school students who currently smoke cigarettes and 31.5% of middle school students and 29.1% of high school students who have never smoked cigarettes rode in a car with someone who was smoking cigarettes; and 3) 71.5% of middle school students and 57.5% of high school students who currently smoke cigarettes and 33.3% of middle school students and 29.9% of high school students who have never smoked cigarettes lived in a home in which someone else smoked cigarettes. Media and advertising influence was also noted, with 58.1% of middle school students and 54.9% of high school students who currently use tobacco and 11.0% of middle school students and 13.7% of high school students who have never used tobacco reporting that they would wear or use an item with a tobacco company name or logo on it. Although 84.6% of middle school students and 91.2% of high school students had seen or heard antismoking commercials on television or radio, 89.9% of middle school students and 91.3% of high school students also had seen actors using tobacco on television or in the movies.

PUBLIC HEALTH ACTIONS

Health and education officials use YTS and NYTS data to plan, evaluate, and improve national and state programs to prevent and control youth tobacco use. States can use these data in presentations to their state legislators to demonstrate the need for funding comprehensive tobacco-control programs, including tobacco cessation and prevention programs for youth.

Perspectives from the Front Lines of Tobacco Control

This research is designed to share valuable experiences and transferable principles from program staff of the Legacy/Community Voices initiative who have been involved in planning, implementing, evaluating, and sustaining tobacco control activities in underserved communities. Interviews were conducted with 13 front line staff from 9 sites: Alameda County, California; Detroit, Michigan; El Paso, Texas; Ingham County, Michigan; Miami, Florida; New Mexico; North Carolina; Northern Manhattan; and West Virginia. A model emerged from these interviews that places the life cycle of a program in a central position, with many of the identified themes (working with local champions, obtaining support from multiple partners, increasing organizational capacity) repeated throughout, albeit in different forms at different stages. Reflecting upon wisdom gained and identifying best processes for such work may help ensure that tobacco control programs are developed that are culturally safe and effective in meeting the needs of diverse communities throughout the United States.

Physician and dentist tobacco use counseling and adolescent smoking behavior: results from the 2000 National Youth Tobacco Survey

OBJECTIVE

The present study describes patterns of tobacco use counseling among physicians and dentists as reported by adolescents and determines the association between provider advice to quit and cessation activities among current smokers.

METHODS

Data were analyzed from the 2000 National Youth Tobacco Survey, an anonymous, self-administered, school-based survey. The National Youth Tobacco Survey was administered to a nationally representative sample of 35828 students in grades 6 to 12 in 324 schools.

RESULTS

Thirty-three percent of adolescents who visited a physician or a dentist in the past year reported that a physician counseled them about the dangers of tobacco use, and 20% reported that a dentist provided a similar message. Among students who smoked in the past year, 16.4% received advice to quit from a physician and 11.6% received advice to quit from a dentist. Physician or dentist advice to quit was correlated with 1 or more quit attempts in the past 12 months.

CONCLUSION

On the basis of adolescent reports, physician and dentist practice patterns remain well below recommended guidelines. Results suggest that provider advice to quit is associated with cessation activity. Additional studies are needed to confirm whether the low prevalence of brief provider tobacco use counseling is a missed opportunity to affect adolescent smoking behavior.

Giving infants a Great Start: Launching a national smoking cessation program for pregnant women

Data suggest that 12%-22% of women smoke during pregnancy. The link between smoking during pregnancy and adverse health and reproductive outcomes has been well documented. Great Start is a public education and smoking cessation program developed especially for pregnant women. Launched in December 2001, Great Start was the first national program focused on providing free and confidential smoking cessation counseling to pregnant women through a toll-free quitline. Great Start consisted of a media campaign to raise awareness and direct women to telephone counseling tailored for the pregnant smoker, and educational materials designed to support pregnant women through cessation counseling. The program was evaluated to assess the ability of the television ads to reach pregnant smokers and the effectiveness of a quitline for increasing cessation rates among pregnant women. Great Start demonstrates that it is possible to reach pregnant smokers through television ads that provide information about the consequences of smoking while pregnant, are affirming in tone, and provide direction for women to take action. Initial response to the program indicates that pregnant women want to quit and confirms the need for programs designed specifically to address the needs of this population.

Preventing 3 million premature deaths and helping 5 million smokers quit: a national action plan for tobacco cessation

In August 2002, the Subcommittee on Cessation of the Interagency Committee on Smoking and Health (ICSH) was charged with developing recommendations to substantially increase rates of tobacco cessation in the United States. The subcommittee's report, A National Action Plan for Tobacco Cessation, outlines 10 recommendations for reducing premature morbidity and mortality by helping millions of Americans stop using tobacco. The plan includes both evidence-based, population-wide strategies designed to promote cessation (e.g., a national quitline network) and a Smokers' Health Fund to finance the programs (through a 2 US dollar per pack excise tax increase). The subcommittee report was presented to the ICSH (February 11, 2003), which unanimously endorsed sending it to Secretary Thompson for his consideration. In this article, we summarize the national action plan.

Who's afraid of the truth?

The November 1998 Master Settlement Agreement between tobacco manufacturers and state attorneys general significantly restricted the marketing of tobacco products, made possible markedly expanded tobacco control programs in the states, and provided for the creation of a new foundation whose primary purpose is to combat tobacco use in the United States. This commentary describes the American Legacy Foundation, with particular emphasis on one of its efforts--the "truth" Campaign, a countermarketing effort to reduce smoking among youths. The "truth" Campaign has been well received by the public and is expected to be [corrected] effective in reducing smoking among youths. The only negative reaction to the campaign has been, predictably, from the tobacco industry.

Women and tobacco: with the master settlement agreement, we've come a long way, baby!

This commentary provides a brief overview of the impact tobacco has on the health of women. Tobacco control activities that reduce the number of young people who start smoking, reduce exposure to environmental tobacco smoke, and increase the ability of Americans to successfully quit have the capacity to markedly reduce the toll of tobacco. The efforts can be greatly enhanced by the unprecedented opportunity the master settlement agreement (MSA) between the state attorneys general and the tobacco industry presents for directing resources to those policies and programs that are most effective in stemming tobacco use. The relentless increase in tobacco marketing reaching teens and ethnic minority women makes ever more urgent our concerted efforts to confront those policy initiatives that can ensure the MSA is adhered to fully.

Effects of ZDV-based patient education on intentions toward ZDV use, HIV testing and reproduction among a US cohort of women

This study examined the immediate effects of exposure to a patient education brochure concerning the risks and benefits of zidovudine (ZDV) therapy during pregnancy to reduce perinatal HIV transmission (protocol ACTG 076) on related knowledge, behavioural intentions and attitudes of women with and at-risk for HIV-infection. Self-reports were collected from 653 women of childbearing age from community family planning clinics and hospital-based HIV centres in 19 sites from nine US cities between May and November 1995. The intervention was a nine-page patient education brochure in Spanish, Creole and English versions, evently presenting the pros and cons of ZDV therapy to reduce perinatal HIV-transmission. Brochure exposure increased knowledge (p < 0.001) for all but one scale concerning ZDV resistance and increased the likelihood of women reporting intentions to take ZDV during pregnancy (p < 0.001) and to believe ZDV reduced transmission (p < 0.001). Brochure exposure had differential effects for some subpopulations. Intentions to have or terminate current or future pregnancies, knowledge about ZDV and attitudes toward ZDV varied mostly by ethnicity/race, language preference and HIV status. Pregnancy status, age, education and having an HIV-positive child had less impact on the brochure's effect, while income had no impact.

Creating training opportunities for public health practitioners

In response to several reports issued by the federal government and private foundations on the under-training of public health practitioners, Joseph L. Mailman School of Public Health of Columbia University (SPH) and the New York City Department of Health (NYC DOH) initiated the Public Health Scholars program (SPH-PHS) to make degree-level public health training available to NYC DOH employees. Public Health Scholars receive a 50% tuition scholarship and enroll part-time while working full-time at NYC DOH. Sixteen scholars have enrolled during the past three years. The SPH-PHS program is considered a success by both SPH and NYC DOH. This article details the history of the collaboration between the two agencies and the structure of the program and provides a critical analysis of the SPH-PHS program based on interviews with 16 scholars. It also examines the cost and benefit to other schools of public health of implementing such a program.

Safer sex strategies for women: the hierarchical model in methadone treatment clinics

Women clients of a methadone maintenance treatment clinic were targeted for an intervention aimed to reduce unsafe sex. The hierarchical model was the basis of the single intervention session, tested among 63 volunteers. This model requires the educator to discuss and demonstrate a full range of barriers that women might use for protection, ranking these in the order of their known efficacy. The model stresses that no one should go without protection. Two objections, both untested, have been voiced against the model. One is that, because of its complexity, women will have difficulty comprehending the message. The second is that, by demonstrating alternative strategies to the male condom, the educator is offering women a way out from persisting with the male condom, so that instead they will use an easier, but less effective, method of protection. The present research aimed at testing both objections in a high-risk and disadvantaged group of women. By comparing before and after performance on a knowledge test, it was established that, at least among these women, the complex message was well understood. By comparing baseline and follow-up reports of barriers used by sexually active women before and after intervention, a reduction in reports of unsafe sexual encounters was demonstrated. The reduction could be attributed directly to adoption of the female condom. Although some women who had used male condoms previously adopted the female condom, most of those who did so had not used the male condom previously. Since neither theoretical objection to the hierarchical model is sustained in this population, fresh weight is given to emphasizing choice of barriers, especially to women who are at high risk and relatively disempowered. As experience with the female condom grows and its unfamiliarity decreases, it would seem appropriate to encourage women who do not succeed with the male condom to try to use the female condom, over which they have more control.

Directly observed therapy and treatment completion for tuberculosis in the United States: is universal supervised therapy necessary?

OBJECTIVES

This study examined the relationship between directly observed therapy and treatment completion rates in the years before and after infusion of federal funding for tuberculosis (TB) control in 1993.

METHODS

An ecological study of estimated directly observed therapy rates and 12-month treatment completion rates from 1990 through 1994 was undertaken for TB control programs in all 25 cities and counties across the nation with 100 or more incident TB cases in any year from 1990 to 1993. Three cohorts were formed: high treatment completion, intermediate completion, and low completion.

RESULTS

In 1990, the median 12-month treatment completion rate was 80% for the entire study population, with a median estimated directly observed therapy rate of 16.8%. By 1994, those rates had increased to 87% and 49.4%, respectively, and increases were shown in all 3 cohorts.

CONCLUSIONS

Directly observed therapy has had a marked impact on treatment completion rates in jurisdictions with historically low rates. But TB treatment completion rates of more than 90% can be attained with directly observed therapy rates far lower than those proposed by advocates of universal supervised therapy.

A decision analysis of mandatory compared with voluntary HIV testing in pregnant women

BACKGROUND

The benefit of antiretroviral therapy in reducing maternal-fetal transmission of HIV during pregnancy has caused a public policy debate about the relative benefits of mandatory HIV screening and voluntary HIV screening in pregnant women.

OBJECTIVE

To evaluate the benefits and risks of mandatory compared with voluntary HIV testing of pregnant women to help guide research and policy.

DESIGN

A decision analysis that incorporated the following variables: acceptance and benefit of prenatal care, acceptance and benefit of zidovudine therapy in HIV-infected women, prevalence of HIV infection, and mandatory compared with voluntary HIV testing.

MEASUREMENTS

The threshold deterrence rate (defined as the percentage of women who, if deterred from seeking prenatal care because of a mandatory HIV testing policy, would offset the benefit of zidovudine in reducing vertical HIV transmission) and the difference between a policy of mandatory testing and a policy of voluntary testing in the absolute number of HIV-infected infants or dead infants.

RESULTS

Voluntary HIV testing was preferred over a broad range of values in the model. At baseline, the threshold deterrence rate was 0.4%. At a deterrence rate of 0.5%, the number of infants (n = 167) spared HIV infection annually in the United States under a mandatory HIV testing policy would be lower than the number of perinatal deaths (n = 189) caused by lack of prenatal care.

CONCLUSIONS

The most important variables in the model were voluntary HIV testing, the deterrence rate associated with mandatory testing compared with voluntary testing, and the prevalence of HIV infection in women of child-bearing age. At high levels of acceptance of voluntary HIV testing, the benefits of a policy of mandatory testing are minimal and may create the potential harms of avoiding prenatal care to avoid mandatory testing.

A balancing act: the tension between case-finding and primary prevention strategies in New York State's voluntary HIV counseling and testing program in women's health care settings

This study sought (1) to identify factors that influence women's willingness to accept voluntary HIV counseling and testing at New York State Family Planning Programs (FPPs) and Prenatal Care Assistance Programs (PCAPs) and (2) to evaluate the effectiveness of such a voluntary counseling and testing program. Telephone interviews elicited organizational-level data from 136 agencies; a combination of telephone and face-to-face interviews was used to gather provider data from 98 HIV counselors; and client data were gathered from 354 women in face-to-face interviews at counseling sites. Slightly fewer than 60% of women agreed to be counseled, and, of those, under half consented to an HIV test at the counseling site. Approximately two thirds of the women who were tested returned for their results and posttest counseling. Clients' recall of pretest counseling content was relatively poor. Bivariate and regression analyses suggest that client, provider, and organizational factors are all associated with rates of pretest counseling and testing. The current voluntary counseling and testing program is achieving only moderate success. Although a substantial number of clients accept HIV counseling, many women remain reluctant to consent to HIV testing, and many who accept testing do not return for their results. Moreover, among those who receive pretest counseling, many do not recall important informational content, which suggests variation may exist in the quality of counseling or that one-time HIV counseling interventions are insufficient to communicate complex information. Medical Subject Headings (MeSH): AIDS, HIV serodiagnosis, women's health, patient education.

The impact of patient education about the effect of zidovudine on HIV perinatal transmission: knowledge gain, attitudes, and behavioral intent among women with and at risk of HIV

The termination of the perinatal HIV transmission trial, ACTG 076, by the Data Safety and Monitoring Board in February 1994 because of the efficacy of zidovudine (ZDV) in substantially reducing maternal-infant HIV transmission has created a considerable need for efficacious patient education approaches and materials for women with and at risk of HIV infection. Complexities surrounding patients' decisions to use ZDV in accordance with the treatment arm protocol of this study must be communicated to women, especially the consequences for both themselves and their potential children. In March 1994, a public-private partnership was formed to develop and test the impact of patient education information on 076 and to explore cultural differences in decision-making surrounding ZDV use during pregnancy. Objectives were (1) to develop an efficacious patient informational booklet on the results of ACTG 076 and (2) to determine the differential attitudes and behavioral intentions of women toward taking AZT during pregnancy. A multi-disciplinary group of providers and researchers developed the patient education booklet and field-tested it in five New York City area sites. Subjects were a multiethnic group of women of childbearing age who were predominantly HIV-positive or at risk of HIV infection (n = 120). This 076 education resulted in a substantial increase in intention to use ZDV to reduce perinatal transmission despite full disclosure of the unknowns (P < .001). There were differences in knowledge acquired between racial/ethnic groups, which must be viewed cautiously since the study did not assess socioeconomic status adequately. Attitudes toward ZDV (P < .05), trust in health care providers (P < .03), and opinions on whether testing should be voluntary (P < .02) also varied by race/ethnicity. Medical Subject Headings (MeSH): perinatal transmission, AIDS education, pregnancy, HIV, ACTG 076.

Stabilizing the HIV/AIDS workforce: lessons from the New York City experience

The Ryan White Title I Personnel Needs Study described here is an evaluation of the human resource needs of HIV/AIDS service agencies in New York City. The research presented here was conducted in collaboration with researchers from the Medical and Health Research Association and the New York City Department of Health and the Planning and Evaluation Committee of the New York City HIV Health and Human Services Planning Council. The assessment is divided into two components. The first component is a survey of 100 key informants from HIV/ AIDS service agencies. The second component is a detailed staffing survey of 70 personnel directors of HIV/AIDS service agencies. HIV/AIDS service directors perceived staff recruitment as a more difficult process than staff retention, regardless of agency type. Vacancy rates at the surveyed agencies varied by professional category; they were especially high in the category of nurse practitioners (13%) and outreach/education workers (15%). Agencies stressed that incentives that would positively affect recruitment and retention should be tailored to address the concerns of varied health care and social service professionals. In addition, agencies were not routinely able to provide some incentives deemed effective such as higher salaries, housing subsidies, and smaller caseloads. To reduce recruitment and retention problems, agency informants recommended a variety of incentive programs including malpractice insurance for physicians, flexible hours for full-time employees (including case managers, nurses, physician's assistants), smaller caseloads, and a decrease in the proportion of staff time devoted to direct client contact. Overall health care trends including truncated federal budgets, state Medicaid cutbacks, and the rapid conversion to managed care all affect the quality of patient care and of the work setting for health care and social service providers serving persons with AIDS. Medical Subject Headings (MeSH): AIDS, health personnel, employment supported, employee workload, staff attitude.