Publications

Abstract

Hepatitis C virus (HCV) infection is a global health problem, and in many countries (including the U.S.), illicit drug users constitute the group at greatest risk for contracting and transmitting HCV. Drug treatment programs are therefore unique sites of opportunity for providing medical care and support for many HCV infected individuals. This paper determines subtypes of a large sample of U.S. drug-free treatment programs (N = 333) according to services they provide to patients with HCV infection, and examines the organizational and aggregate patient characteristics of programs in these subtypes. A latent class analysis identified four subtypes of HCV service provision: a "Most Comprehensive Services" class (13% of the sample), a "Comprehensive Off-Site Medical Services" class (54%), a "Medical Monitoring Services" class (8%) and a "Minimal Services" class (25%). "Comprehensive" services class programs were less likely to be outpatient and private for profit than those in the other two classes. It is of concern that so many programs belong to the "Minimal Services" class, especially because some of these programs serve many injection drug users. "Minimal Services" class programs in the U.S. need to innovate services so that their HCV infected patients can get the medical and support care they need. Similar analyses in other countries can inform their policy makers about the capacity of their drug treatment programs to provide support to their HCV infected patients.

Abstract

Background: Endothelial dysfunction precedes overt atherosclerosis and is present in patients with type 2 diabetes mellitus (T2DM). Myocardial perfusion imaging (MPI) is an effective method of detection of coronary artery disease (CAD); however, the relationship between endothelial function and MPI in asymptomatic patients with T2DM has not been examined. Methods and Results: This study used a subset of the population from the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study. Endothelium-dependent vasodilation (EDV) and endothelium-independent vasodilation (EIV) were measured by use of brachial artery ultrasonography in 75 asymptomatic patients with T2DM (56 men; mean age, 58.6 ± 6.4 years; mean duration of diabetes, 8.4 ± 7.5 years) who underwent adenosine MPI. Of the patients, 15 (20%) had evidence of relative ischemia (MPI+) whereas 60 (80%) had a normal study (MPI-). Both EDV (3.5% ± 3.7% vs 4.5% ± 6.6%, P = not significant) and EIV (15.1% ± 7.5% vs 16.8% ± 8.4%, P = not significant) were similar in the 2 groups. On the basis of a receiver-operator analysis, an EDV response of 8% was selected as a cut point, with a negative predictive value of 93% (13/14 subjects with EDV ≥8% were MPI-). Conclusions: Endothelial function in asymptomatic patients with T2DM is not associated with the presence of relative myocardial ischemia by MPI; however, an EDV of 8% or greater has a high negative predictive value for the exclusion of CAD.

Abstract

PROBLEM. This study describes the impact of the experience of dating violence on the daily lives of college women. METHODS. Qualitative content analysis was used to analyze transcribed responses from an open-ended question about the impact of dating violence. FINDINGS. Eight thematic categories emerged: emotional distress, distrust and using extra precautions, disconnected and distant in relationships, self-discontentment, disclaiming the experience, feeling disenfranchised, life disruption, and turning a situation from disempowering to empowering. CONCLUSIONS. Understanding the perspective of dating violence victims assists the advanced practice psychiatric nurse (APPN) with planning effective care. Routine screening about past and present experiences of violence must occur with all young women. Providers must be knowledgeable about available resources for victims.

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

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

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: Optimal elements of a sexual history for sexually transmitted infection (STI) and HIV risk assessment remain undefined. Goal: The goal of this study was to describe sexual histories in use at STI clinics across the United States. Study: This study consisted of a cross-sectional survey of facilities in cities with populations > 200,000 (n = 65). Within each city, a public health STI clinic (71% of the sample) or other STI care facility (29%) was randomly selected and sexual history forms were requested. Information was obtained from 48 clinics (74% response). Results: Most forms recorded information on symptoms and prior STI (96%), condom use (88%), other contraception (85%), and numbers and gender (83%) of sex partners. Common HIV risk questions were injecting drug use (IDU; 94%), sex for drugs or money (58%), and sex with an HIV-positive or IDU partner (52%). Ascertainment of time during which risks occurred (contact periods) varied from the past 14 days to the past 12 months, with only 38% of clinics using any 1 time period. Few histories (17%) incorporated questions for men who have sex with men (MSM). Only 2 (4%) had space to record Information about sexual behaviors by the HIV status of the sex partner. Condom use was infrequently assessed specifically for vaginal and anal sex (13%), and condom use problems were rarely explored (10%). Most forms documented STI/HIV counseling, although few (25%) included specific risk reduction plans. Conclusions: Sexual histories are highly variable. Although challenging to accomplish, STI/HIV care, surveillance, and prevention may be improved by developing consensus on core questions to be used in sexual histories.

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

Objective: To develop a preliminary epidemiological description of a men who have sex with men (MSM) "POZ Party," an emerging sex environment for HIV+ MSM. Methods: As part of a pilot study in New York City in 2003, data were collected using a brief, behavioural intercept survey at entry to POZ Party events. Domains include demographic characteristics, history of HIV infection, motivations for attending POZ parties, lifetime and recent exposure to drugs (including use during POZ Party events), and recent sexual practices (both within both POZ Party venues as well as in non-POZ Party venues). Results: Predominantly white and over the age of 30, subjects in the sample include a broad range of years living with HIV infection. Motivations for using a POZ Party venue for sexual partnering include relief from burdens for serostatus disclosure, an interest in not infecting others, and opportunities for unprotected sexual exchange. High rates of unprotected sex with multiple partners are prevalent in the venue. Although the sample evidences high rates of lifetime exposure to illicit drugs, relatively little drug use was reported in these sexual environments. These reports are consistent with evidence from direct observation at the venues themselves, in which no drug use was apparent. Conclusion: Serosorting among HIV+ MSM may reduce new HIV infections, a stated interest of both POZ Party organisers and participants alike. However, high rates of unprotected anal intercourse within these venues signal continued risk for STIs. Additionally, unprotected sexual contact with HIV partners and status unknown partners outside POZ Party venues heightens concern for diffusion of HIV superinfection.

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.