Publications

Abstract

The 1997 Medical Expenditure Panel Survey (MEPS) data report that approximately 80 million adult ambulatory visits are made to nursing personnel. Adults who visit nursing personnel and who visit physicians are similar with regard to sex and income. As compared to nursing personnel, physician visits are longer and more likely to involve diagnosis or treatment. Older adult visits (ages 65 to 90) to nursing personnel are significantly longer than the visits of younger adults. As compared to physician visits, nursing personnel visits are significantly more likely to be characterized as “other” for all adults and especially for older adults. Although these findings suggest important differences between physician and nurse ambulatory care visits, the undifferentiated use of the term nurse and the significant percentage of uncharacterized visits to nursing personnel signal serious deficiencies in the MEPS data in exploring nonphysician ambulatory care.

Abstract

The purpose of this study is to examine the impact of culture on contributory behaviors within the context of family, friends, and neighbors among the oldest old in the United States and in China. The study was conducted in suburban areas of Boston in 1996 (n = 465), and later in 1999 a replication of the study was conducted by Chinese researchers in urban areas of Shanghai, China (n = 539). This study found some common factors such as objective measure of health status, assistance received from others, and group affiliation. However, many differences emerged in the study. The range of contributory behaviors toward friends is quite different between the two samples. Some of the correlates' impact is also culturally specific, such as sibling support. These differences reflect variation in respondents' social support as well as social structural differences. Findings from this study suggest that providing more opportunities for elders to participate in groups would facilitate their participation in volunteer activities and improve their overall well-being.

Abstract

Although progress has been made in understanding the pathophysiology of asthma and identifying key features of quality asthma care, the prevalence of childhood asthma remains high. Barriers to effective asthma care that currently exist include the persistence of environmental risk factors, disparities in care that stem from poverty and cultural differences, and inconsistencies in the quality of asthma care provided by clinicians. Pediatric nurse practitioners at Yale New Haven Children's Hospital have actively implemented the recommended guidelines for asthma care and addressed causes for some of the disparities in asthma health care. Two major initiatives are described: the Asthma Care Coordination Project at Yale New Haven Hospital Pediatric Primary Care Center, and the establishment of an Asthma Outreach Program. Recommended resources and Web sites for the practitioner are also provided.

Abstract

Purpose: The purpose of this study was to explore food purchasing, preparation, and consumption among black women with type 2 diabetes mellitus (T2DM) in an urban setting to assess barriers to medical nutrition therapy recommendations. Methods: A telephone survey was developed to assess shopping habits, the use of community resources for food supplementation, use of restaurant/fast-food establishments, dining habits, food purchasing and consumption, and food preparation methods. This 38-item questionnaire provided both frequencies and trends regarding participants' dietary habits. Results: Black women identified ways in which their participation in a culturally competent intervention of diabetes care and education helped them to change dietary behaviors. The most common areas of change included purchasing, preparation, and portion size. Barriers to medical nutrition therapy identified included low income, time constraints, competing demands, and knowledge deficits. Conclusions: Culturally sensitive diabetes interventions are an effective way to overcome some of the barriers to medical nutrition therapy. Feedback provided by this survey suggests that identification of more affordable healthy food resources in the community is necessary. In addition, access issues such as transportation to grocery stores should be on the agenda for public policy issues. Finally, alternate sites for nutrition education, such as a supermarket forum, warrant further investigation.

Abstract

Background: In surveys, clients have expressed preferences for alternatives to traditional HIV counseling and testing. Few data exist to document how offering such alternatives affects acceptance of HIV testing and receipt of test results. Objectives: This randomized controlled trial compared types of HIV tests and counseling at a needle exchange and 2 bathhouses to determine which types most effectively ensured that clients received test results. Methods: Four alternatives were offered on randomly determined days: (1) traditional test with standard counseling, (2) rapid test with standard counseling, (3) oral fluid test with standard counseling, and (4) traditional test with choice of written pretest materials or standard counseling. Results: Of 17,010 clients offered testing, 7014 (41%) were eligible; of those eligible, 761 (11%) were tested: 324 at the needle exchange and 437 at the bathhouses. At the needle exchange, more clients accepted testing (odds ratio [OR] = 2.3; P < 0.001) and received results (OR = 2.6; P < 0.001) on days when the oral fluid test was offered compared with the traditional test. At the bathhouses, more clients accepted oral fluid testing (OR = 1.6; P < 0.001), but more clients overall received results on days when the rapid test was offered (OR = 1.9; P = 0.01). Conclusions: Oral fluid testing and rapid blood testing at both outreach venues resulted in significantly more people receiving test results compared with traditional HIV testing. Making counseling optional increased testing at the needle exchange but not at the bathhouses.

Abstract

This article describes the recruitment and retention strategies implemented for a prospective, randomized, clinical trial conducted at a single study facility. The purpose of the study was to examine the effects of a nutritional intervention to reduce the episodes of diarrhea in patients with the human immunodeficiency virus/acquired immune deficiency syndrome. This article reviews the challenges faced by the research team during the conduct of the study and discusses the approaches implemented to reduce the barriers to study participation.

Abstract

This paper describes findings from a study of young men who have sex with men (YMSM) in New York City. Using a cross-sectional design and a community-based targeted sampling approach, a total of 569 YMSM were recruited during 2000 and 2001 for a structured survey interview. High rates of lifetime exposure to a variety of club drugs (including methamphetamine, ketamine, and MDMA) are observed in the overall sample. Among those who use club drugs on a chronic basis (N = 145), we found high rates of a prior suicide attempt (including high rates of multiple suicide attempts), high rates of lifetime exposure to multiple types of drugs, high rates of current poly drug use (including multiple types of club drugs), and high rates of current depressive symptoms. Chronic club drug users had a mean CES-D score of 8.5 and nearly two-thirds had a score of 7 or more. Although high rates of condom use are reported in some types of sexual exchanges, data show multiple types of sexual risk among chronic club drug users, including high rates of unprotected anal intercourse (UAI) with most frequent partners and comorbid drug use among both YMSM and their sexual partners.

Abstract

Background: Few studies have examined physician-family caregiver communication at the end of life, despite the important role families have in end-of-life care decisions. We examined family caregiver reports of physician communication about incurable illness, life expectancy, and hospice; the timing of these discussions; and subsequent family understanding of these issues. Design: Mixed methods study using a closed-ended survey of 206 family caregivers and open-ended, in-depth interviews with 12 additional family caregivers. Setting/Subjects: Two hundred eighteen primary family caregivers of patients with cancer enrolled with hospice between October 1999 and June 2002 Measurements: Family caregiver reports provided at the time of hospice enrollment of physician discussions of incurable illness, life expectancy, and hospice. Results: Many family caregivers reported that a physician never told them the patient's illness could not be cured (20.8%), never provided life expectancy (40% of those reportedly told illness was incurable), and never discussed using hospice (32.2%). Caregivers reported the first discussion of the illness being incurable and of hospice as a possibility occurred within 1 month of the patient's death in many cases (23.5% and 41.1%, respectively). In open-ended interviews, however, family caregivers expressed ambivalence about what they wanted to know, and their difficulty comprehending and accepting "bad news" was apparent in both qualitative and quantitative data. Conclusion: Our findings suggest that ineffective communication about end-of-life issues likely results from both physician's lack of discussion and family caregiver's difficulty hearing the news. Future studies should examine strategies for optimal physician-family caregiver communication about incurable illness, so that families and patients can begin the physical, emotional, and spiritual work that can lead to acceptance of the irreversible condition.

Abstract

Objectives. We evaluated the effectiveness of an intervention designed to increase preventive health care seeking among adolescents. Methods. Adolescents and young adults aged 12 to 21 years, recruited from community-based organizations in 2 different communities, were randomized into either a 3-session intervention or a control condition. We estimated outcomes from 3-month follow-up data using logistic and ordinary least squares regression. Results. Female intervention participants were significantly more likely than female control participants to have scheduled a health care appointment (odds ratio [OR]=3.04), undergone a checkup (OR=2.87), and discussed with friends or family members the importance of undergoing a checkup (OR=4.5). There were no differences between male intervention and male control participants in terms of outcomes. Conclusions. This theory-driven, community-based group intervention significantly increased preventive health care seeking among female adolescents. Further research is needed, however, to identify interventions that will produce successful outcomes among male adolescents.

Abstract

Objective: The purpose of the study was to identify factors predictive of use of dental services among Chinese- and Russian-speaking immigrant elders. Methods: The data for this analysis were collected from the 1997 survey "Assessing public health and health care needs of Russian-speaking elderly immigrants." A similar survey was replicated among Chinese-speaking elderly immigrants in 2000. Community-based samples of 300 Russian elders and 177 Chinese elders were recruited for the study. Results: Chinese elders used dental care services at lower rates than Russian elders. Education, length of stay in the US, social support, and smoking behavior were significant predictors for the use of dental services among Chinese. However, among Russian elders, age, income, and denture use predicted utilization of dental services. Conclusions: Although Chinese- and Russian-speaking elders have similar immigrant experiences and share the same geographic location and urban setting, the two groups have different patterns of dental service use. These differences may be due to differences in socio-demographic characteristics, values, attitudes and knowledge of oral health and dental care, and unique cultural backgrounds.

Abstract

This study examined a five-factor model of the Spiritual Well-Being Scale (SWBS; Ellison, 1983) proposed by Miller, Fleming, and Brown-Anderson (1998). A confirmatory factor analytic procedure was conducted to determine whether the Miller et al. model fit the data for the current sample of African Americans. For comparative purposes, several alternative SWBS models were included in the study's design. The findings indicated that none of the SWBS models provided an adequate fit to the data for the current sample. Implications for future use of the SWBS with African American populations are discussed.

Abstract

The objective of this study was to determine the direct cost of HIV adherence support programmes participating in a cross-site evaluation in the US. Data on the frequency, type, and setting of adherence encounters; providers' professions; and adherence tools provided were collected for 1,122 patients enrolled in 13 interventions at 9 sites. The site staff estimated the average duration of each type of encounter and national wage rates were used for labour costs. The median (range) adherence encounters/year among interventions was 16.5 (4.3-104.6) per patient; encounters lasted 24.6 (8.9-40.9) minutes. Intervention direct cost was correlated with the average frequency of encounters (r = 0.57), but not with encounter duration or providers' professions. The median direct cost/month was $35 ($5-$58) per patient, and included direct provider costs (66%); incentives (17%); reminders and other tools (8%); and direct administrative time, provider transportation, training, and home delivery (9%). The median direct cost/month from a societal perspective, which includes patient time and travel costs, was $47 ($24-$114) per patient. Adherence interventions with moderate efficacy costing ≤$100/month have been estimated to meet a cost-effectiveness threshold that is generally accepted in the US. Payers should consider enhanced reimbursement for adherence support services.

Abstract

Background: Persons who have been infected with chlamydia or gonorrhea (CT/GC) are at elevated risk for reinfection. The cost-effectiveness of interventions designed to encourage public sexually transmitted disease (STD) clinic patients to return for rescreening has not been well-evaluated. Goal: The goal of this study was to conduct a program- and societal-perspective cost-effectiveness analysis of five interventions designed to encourage public STD clinic patients infected with CT/GC to return for rescreening 3 months after initial treatment. Study: Researchers at two STD clinics collected cost data for the five interventions. These were combined with study data on return rates and CT/GC positivity rates among returning patients to compare the cost-effectiveness of the interventions. Results: The cost per patient counseled with a brief recommendation to return, followed by a telephone reminder after 3 months, was higher than two interventions: a brief recommendation to return with no reminder and a $20 incentive, received on return. However, the brief recommendation with a telephone reminder yielded the highest return rate (33%) and was the least costly in terms of cost per infection treated ($622 program, $813 societal). In-depth motivational counseling that helped clients identify risk factors and provided reasons for returning was more costly than a phone reminder alone and was not more effective. Conclusions: Phone reminders are more cost-effective than motivational counseling and improve return rates over a brief recommendation given at the time of initial treatment.

Abstract

▶ Background: College-aged women report experiencing violence from a partner within the dating experience. ▶ Objectives: This study used a correlational design, to report physical injury, mental health symptoms, and healthcare associated with violence in the dating experiences of college women. ▶ Methods: A convenience sample of 863 college women between 18 and 25 years of age from a private, historically Black university in the South, and a private college in the mid-Atlantic completed the Abuse Assessment Screen, a physical injury checklist, and the Symptom Checklist - R-90. Data analysis consisted of frequencies, ANOVA, and MANOVA. ▶ Results: Almost half (48%) (n = 412) reported violence and, of these, 39% (n = 160) reported more than one form of violence. The most commonly reported injuries were scratches, bruises, welts, black eyes, swelling, or busted lip; and sore muscles, sprains, or pulls. Victims had significantly higher scores on depression, anxiety, somatization, interpersonal sensitivity, hostility, and global severity index than nonvictims. Victims of multiple forms of violence had significantly higher mental health scores and reported greater numbers of injuries than victims of a single form of violence. Less than half of those injured sought healthcare for injuries and less than 3% saw a mental health professional. ▶ Discussion: Study findings suggest the importance of screening and identification of victims of violence. Knowledge of physical and mental health effects of violence can guide intervention, prevention, and health promotion strategies. Future research is needed to describe barriers to seeking healthcare, screening practices of college health programs, and programs to identify victims.