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PubMed1997

Participatory evaluation of counselling, medical and social services of The AIDS Support Organization (TASO) in Uganda.

The AIDS Support Organization (TASO) is an indigenous non-governmental organization (NGO) of HIV-infected and affected people in Uganda. TASO provides counselling, social support, medical and nursing care for opportunistic infections at 7 centres affiliated to district hospitals in Uganda. Between 1993 and 1994, the services provided by TASO were evaluated through a participatory approach between staff and clients. TASO counselling services helped clients and their families to cope with HIV and AIDS, with 90.4% of clients revealing their serostatus, and 57.2% reporting consistent use of condoms in the past 3 months. TASO was also the main source of medical care for clients with opportunistic infections in the last 6 months (63.8%). As a result of counselling, over half of the clients (56.9%) made plans for the future and 51.3% wished to make wills. There was a high level of acceptance of people living with HIV/AIDS (PWAs) by families (79%) and the community (76%). Care was provided to PWAs at home mainly by women (86.2%). TASO has demonstrated that individuals and their families are able to live positively with HIV/AIDS. Through counselling, medical care and material support to clients and their families, TASO has effected change in people's attitudes, knowledge and lifestyles. In particular, TASO has demonstrated a strong capacity to overcome four problems that haunt AIDS care in most places: (1) revealing one's HIV-serostatus to relevant others; (2) accepting PWAs in family and community; (3) seeking early treatment; and (4) combining prevention and care. In general, TASO has shown that specialized services to meet AIDS care needs can be added to existing health services at district levels. As a result of the participatory evaluation, a well-accepted monitoring system was established.

AIDS-Related Opportunistic Infections↗

PubMed2001

Design of regimens for treating tuberculosis in patients with HIV infection, with particular reference to sub-Saharan Africa.

The highest burden of human immunodeficiency virus (HIV) related tuberculosis (TB) is in sub-Saharan Africa. HIV complicates several areas of TB control, one of which involves treatment and treatment outcome. Large patient numbers cause congestion on TB wards, there is increased morbidity, an increased risk of adverse drug reactions, an increased case fatality, and an increased recurrence of TB after treatment completion. TB Control Programmes have responded to these problems by taking actions such as abolishing thioacetazone and decentralising the initial phase of treatment to peripheral health centres and the community. Despite this response, there are three major on-going concerns which need to be addressed by research studies. There is a need to reduce case fatality rates focusing on 1) stronger treatment regimens, 2) adequacy of rifampicin levels when intermittent treatment regimens are used, and 3) adjunctive treatments. There is a need to reduce recurrent rates of TB by 1) determining the relative role of re-infection and reactivation as a cause of recurrence, 2) assessing the importance of duration and type of anti-TB treatment for the first episode of TB, and 3) determining the role of secondary isoniazid preventive therapy. There is a need to evaluate how best to decentralise treatment from the perspective of the health service and the patient. Research studies should be relevant to the needs and resources of TB control programmes, and should include pharmacokinetic studies, controlled clinical trials and operational research, including economic analysis and social science evaluation.

AIDS-Related Opportunistic Infections↗

PubMed1999

Community-based dental programs: University of Medicine and Dentistry of New Jersey-New Jersey Dental School.

The dental school plans to incorporate CODE into the curriculum so that more students have community-based dental educational experiences. Future plans also include increasing standardization of reports, clinical and administrative procedures, resources, and processes across the sites in order to lower managerial overhead. This process will be aided by further enhancement of computerized information systems and electronic links. The major lesson learned is that new extramural programs can be created and sustained by pooling school resources with those from the private and public sectors. Funding sources and opportunities available to one party alone are insufficient. While one-time funding was used to build and furnish the NJDS extramural sites, the clinics were established only after business plans demonstrated the availability of funds to sustain their operations. The Statewide Network of Community Oral Health Care and CODE models are still evolving, but they are replicable not only in dental education but in other types of health services. The details of the partnerships and funding streams will vary from site to site, but through outreach and careful negotiation with potential partners and detailed contracts, the community service and educational missions of a health professions school can have a successful outcome.

Community Dentistry↗

PubMed1999

Service delivery for patients with HIV in a rural state: the Vermont model.

The incidence of human immunodeficiency virus (HIV) infection is increasing rapidly in rural areas of the United States. Barriers to health-care delivery for this patient population include the complexity of this rapidly changing field, inexperienced rural physicians, long travel distances to receive expert care, lack of psychosocial support systems, and concerns about confidentiality. Models of HIV care for rural areas have not been developed that remove these barriers. We present the philosophy, structure, implementation, and services of a model of care in Vermont that is designed to remove many of these barriers and bring HIV expertise into the rural areas of the state. Three HIV specialty clinics have been developed in regional hospitals throughout the state. The clinic team includes an HIV-trained nurse practitioner and social worker from the hospital, a client consultant from the regional AIDS service organization, and an infectious disease specialist who travels to each of the clinics monthly. Patient care will be centralized in these regionally located clinics. The dispersion of HIV care among numerous and inexperienced rural providers will be obviated. Confidentiality will be emphasized within the hospital environment. The model has the potential to provide a complete continuum of medical care and psychosocial case management, integrate patient care and regional provider education, and increase community awareness. Patients will be able to receive their care in their own community, avoiding long travel distances. This may encourage patients to seek care earlier in their illness. The model may be adaptable to other rural areas of the United States.

Case Management↗

PubMed1990

The use of interactive media for HIV/AIDS prevention in the military community.

Over 50 years of risk-reduction efforts for sexually transmitted diseases (STD) exist as a foundation for Acquired Immunodeficiency Disease Syndrome (AIDS) prevention programs in the military, yet very few innovative prevention concepts have been generated. However, the military has used interactive media successfully in medical education to supplement instructional lessons, demonstrate surgical procedures, and train soldiers in mass casualty and combat trauma. The Department of Defense plans to use interactive media in the military's STD clinics for AIDS education. The media combines the visual flexibility of an interactive videodisc with the storage and retrieval capabilities of a computer to display text, graphics, photos, and full-motion media. Rather than a completely descriptive or didactic approach to STD and AIDS prevention activities, a novice user can see and interact with an immediate-motion video representation on the screen. This is important in modifying behavior patterns and demonstrating their relationship to the transmission of the AIDS virus. The development of an interactive videodisc on HIV prevention for use in the military's STD clinics will be discussed, as well as the expedience of their multifaceted use in delivering AIDS information.

Acquired Immunodeficiency Syndrome↗

PubMed1993

Effect of prenatal and infancy nurse home visitation on government spending.

A completed series of reports on a randomized trial (N = 400) indicated that, in contrast to comparison services, prenatal and infancy nurse home visitation improved a wide range of maternal and child health outcomes among poor, unmarried, and teenaged women bearing first children in a semirural county in upstate New York. Eighty-nine percent of the sample was white, and all analyses focused on this group. In this article, an analysis of the net cost of the home-visitation program from the perspective of government spending is presented. The average per-family cost of the program in 1980 dollars was $3,246 for the sample as a whole, and $3,133 for low-income families. Treatment differences in government expenditures for Aid to Families with Dependent Children, Food Stamps, Medicaid, and Child Protective Services, minus tax revenues due to maternal employment (also expressed in 1980 dollars), were conceived as government savings. By the time the children were 4 years of age, government savings were $1,772 (95% confidence interval [CI]: -$557, $4,102) for the sample as a whole, and $3,498 (95% CI: $569, $6,427) for low-income families. Within 2 years after the program ended, after discounting, the net cost of the program (program costs minus savings) for the sample as a whole was $1,582 per family. For low-income families, the cost of the program was recovered with a dividend of $180 per family.

Adolescent↗

PubMed2002

Mental health literacy of those with major depression and suicidal ideation: an impediment to help seeking.

Mental health literacy is the knowledge and beliefs about mental disorders that aid their recognition, management, or prevention, and is an important determinant of help seeking. This has relevance in suicide prevention, particularly for those with major depression, the clinical condition most frequently associated with suicidal behavior. In this study of a random and representative community sample, a vignette depicting classical features of major depression was presented to subjects along with questions related to mental health literacy. The responses of those with major depression, as delineated by the Primary Care Evaluation of Mental Disorders instrument, both with and without suicidal ideation, were compared to those of a third group of respondents. The results demonstrated that despite increased professional contact by those with major depression and suicidal ideation, there were few differences among the three groups on either open-ended or direct questions related to mental health literacy. This indicates that increased professional contact in itself was not related to increased mental health literacy, and suggests that more specific psychoeducational programs are required.

Adult↗

PubMedDate not supplied

The Medicaid program and consumer needs: a survey among residents of a poor Chicago neighborhood.

A convenience sample of 200 inner-city residents were interviewed about their knowledge of benefits available under the Illinois Medicaid fee-for-service and prepaid programs; a second sample of 200 residents from the same community were interviewed about their health care information needs. All respondents were recruited from a Chicago neighborhood with one of the nation's highest rates of poverty, infant mortality, and births of low birth weight infants. The neighborhood also has been targeted as a demonstration site for an Illinois Department of Public Aid's prepaid Medicaid program. Responses to the first interview indicated that neighborhood residents did not understand the operational features of Medicaid prepaid plans or the programmatic mission of these plans, and they did not want to enroll in existing prepaid plans. As determined in the second interview, residents desired information on the scope of Medicaid services, ways to assess quality of health care received, and options for maintaining their freedom to choose hospitals and physicians or clinics. The survey findings are compared with what is known about the reasons middle class employed families enroll in and disenroll from prepaid plans and the position of poor families in a cost-conscious health care system.

Aid to Families with Dependent Children↗

PubMed1986

Smoking cessation: a practical guide for the physician.

Physicians play critical roles in efforts to encourage nonsmoking, both in their individual interventions with smokers and in their contributions to broader political, educational, and public health efforts to encourage nonsmoking. These broader efforts, much aided by the authority and concern of individual physicians and organized medicine will continue, also, to provide a supportive background for individual clinical efforts. Together, the broad based and the clinical activity potentiate each other in decreasing the prevalence of smoking. The difficulties individuals experience in quitting smoking are best understood when placed within the context of the billion dollar marketing of an addictive product; the reality that quitting smoking occurs gradually over time, many smokers attempting to quit several times before succeeding; and the influence of physicians' continuing clinical and community activity in maintaining a culture actively cognizant of the risks of smoking. Through brief clinical counseling as outlined in this article, physicians can help almost all of their smoking patients move toward becoming a nonsmoker by trying to quit or, at least, giving greater thought to doing so. Additionally, the physician can help patients eager to quit by referral to well developed programs and materials such as have been described. In all, then, numerous effective resources are available for the clinician who wishes to deal responsibly with the most important preventable cause of morbidity and mortality in the approximately 30 per cent of patients who smoke.

Counseling↗

PubMed1996

Changes in HIV risk behavior following alternative residential programs of drug abuse treatment and AIDS education.

We compared the effectiveness in changing human immunodeficiency virus (HIV) risk behavior of two different approaches to acquired immunodeficiency syndrome (AIDS) education given by residential drug abuse treatment programs differing in their planned duration. Two randomized controlled trials compared (a) a 6-month with a 12-month therapeutic community (TC) program, and (b) a 6-month with a 3-month relapse prevention (RP) program. Three composite variables assessing HIV risk (a) drug injection, (b) sexual partners, and (c) condom use-were measured for the 3 months prior to admission and follow-up. The TC program comprised a four-part AIDS information intervention. The RP program comprised a 21- or 42-session small-group program in the principles of RP, 5 skills-building AIDS education sessions, and 6 other health education sessions. Four hundred ninety-five clients were enrolled in the study and completed a follow-up interview within 6 months of exit (79% of those enrolled). Clients in the RP program reduced their drug injection and condom use risk. Female clients in the TC program reduced their condom use risk. There were no differential effects on risk behavior change of either planned duration (randomization assignment) or program type (RP versus TC). Thus, differences in the treatment programs, including AIDS education components, had no apparent effect on HIV risk behavior change. The contribution of residential drug abuse treatment programs to AIDS prevention remains unproved.

Adult↗

PubMed2004

The process of changing health risk behaviors: an Oregon rural clinic experience.

PURPOSE: A counseling intervention was conducted by nurse practitioners (NPs) at a rural clinic in Oregon. The intervention was designed to help individuals change health risk behaviors. Three focus groups were conducted to aid in understanding the barriers to changing health behaviors and to identify resources that rural individuals needed to succeed in behavior change. DATA SOURCES: Quantitative data were collected using appraisal forms that were specific to five behaviors. Qualitative data were from written comments submitted by focus group participants in answer to questions sent prior to each meeting and from written summaries of focus group meetings submitted by the focus group leader. CONCLUSIONS: Most participants were not successful in changing their health behaviors. The issues raised in the focus group discussions provide an overview of the barriers to health behavior change as perceived by a group of adults in a rural environment. Both individual lack of will and the rural community environment were barriers to adopting new health behaviors. IMPLICATIONS FOR PRACTICE: NPs in rural health care clinics could provide important support for individuals attempting to adopt new health behaviors. Specific suggestions from focus group participants included discussing risky behaviors more often, forming support groups that do not charge a fee, and developing a peer-mentoring program.

Adult↗

PubMed2003

Acceptability study of sex workers attending the HIV/ AIDS clinic in Ruili, China.

A charitable clinic was set up to provide HIV/STD education and care to commercial sex workers in Ruili. Despite regular promotion of the clinic, few people had utilised the service. Therefore, a qualitative study was carried out among 89 sex workers between March and April 2001 to look at the background of our target group, their medical-seeking behaviours and the range of services expected. The turnover rates of sex workers were high. They had good awareness but poor knowledge of STD/HIV. Many self-medicated or sought advice from peers. They had a serious concern for private practitioners or the quality of drugs from pharmacy stores. They found our clinic inconvenient and did not meet their needs. Subsequently, we refurbished the clinic, implemented changes and retrained our staff. The number of patients treated three weeks after re-opening of the clinic has increased by three folds, with many of them still sex workers, and the clinic's income increased by 58%. Our experience has important implications for policymakers and other NGOs working with sex workers.

Adolescent↗

PubMed1992

AIDS and family planning counseling of psychiatrically ill women in community mental health clinics.

Eighty-two of 83 mental health professionals, including psychiatrists, were surveyed to determine their attitudes and behaviors toward AIDS prevention and family planning counseling with psychiatrically ill female outpatients. Nearly all reported that information should be provided on AIDS and family planning. However, they reported that they had raised topics of AIDS with only 19% of patients and family planning with only 25% of patients. This lack of communication was confirmed by patients' own reports. Factors which might relate to this lack of communication are explored.

Acquired Immunodeficiency Syndrome↗

PubMed1997

Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial.

CONTEXT: Home-visitation services have been promoted as a means of improving maternal and child health and functioning. However, long-term effects have not been examined. OBJECTIVE: To examine the long-term effects of a program of prenatal and early childhood home visitation by nurses on women's life course and child abuse and neglect. DESIGN: Randomized trial. SETTING: Semirural community in New York. PARTICIPANTS: Of 400 consecutive pregnant women with no previous live births enrolled, 324 participated in a follow-up study when their children were 15 years old. INTERVENTION: Families received a mean of 9 home visits during pregnancy and 23 home visits from the child's birth through the second birthday. DATA SOURCES AND MEASURES: Women's use of welfare and number of subsequent children were based on self-report; their arrests and convictions were based on self-report and archived data from New York State. Verified reports of child abuse and neglect were abstracted from state records. MAIN RESULTS: During the 15-year period after the birth of their first child, in contrast to women in the comparison group, women who were visited by nurses during pregnancy and infancy were identified as perpetrators of child abuse and neglect in 0.29 vs 0.54 verified reports (P<.001). Among women who were unmarried and from households of low socioeconomic status at initial enrollment, in contrast to those in the comparison group, nurse-visited women had 1.3 vs 1.6 subsequent births (P=.02), 65 vs 37 months between the birth of the first and a second child (P=.001), 60 vs 90 months' receiving Aid to Families With Dependent Children (P=.005), 0.41 vs 0.73 behavioral impairments due to use of alcohol and other drugs (P=.03), 0.18 vs 0.58 arrests by self-report (P<.001), and 0.16 vs 0.90 arrests disclosed by New York State records (P<.001). CONCLUSIONS: This program of prenatal and early childhood home visitation by nurses can reduce the number of subsequent pregnancies, the use of welfare, child abuse and neglect, and criminal behavior on the part of low-income, unmarried mothers for up to 15 years after the birth of the first child.

Adolescent↗

PubMed1991

Incorporating HIV education and counseling into routine prenatal care: a program model.

This article reports how a prenatal clinic in a major urban teaching hospital has developed and integrated an HIV education and counseling program into routine prenatal care. The patient population served are predominantly minority women living in an inner-city community that has been disproportionately affected by the AIDS epidemic. Implementation of the patient program has required training and support for all professional staff. Staff training served as a foundation for this comprehensive patient program, which has reached all prenatal patients regardless of risk behavior. The program has succeeded in involving a large population of women in an educational program, has identified HIV-1 seropositive pregnant women through voluntary testing, and has provided them with the necessary medical and social work services. Principles of program development are identified for use in other settings.

Ambulatory Care↗

PubMed1995

Practicing population-based care in an HMO: evaluation after 18 months.

OBJECTIVE: To determine whether population-based care in a primary care practice results in improvement in compliance with patient care guidelines. DESIGN: Time series analysis. SETTING: One primary care practice in Group Health Cooperative of Puget Sound (GHC). PARTICIPANTS: Approximately 1500 enrollees cared for by the practice. INTERVENTIONS: An ongoing approach to aid clinical planning at the level of the primary care team--population-based care--that depends on clinical guidelines, a computing system to provide epidemiologic data on guideline performance in the practice and reminders, and a process whereby the practice team analyzed and designs interventions for specific clinical problems. MAIN OUTCOME MEASURES: We compared compliance with practice guidelines for preventive care and chronic illness management at baseline and after 18 months in the intervention population with other patients in the same clinic and with patients in GHC as a whole. RESULTS: Compliance with breast cancer screening and colorectal cancer screening guidelines in the intervention population increased from baseline 32% and 18% respectively. These increases were significantly greater than in the remainder of the clinic or in GHC as a whole. CONCLUSIONS: The availability of practice-based data, clinical guidelines and a local intervention design process resulted in significant improvements in compliance with patient care guidelines.

Algorithms↗

PubMed1988

The impact of the "grim reaper" national AIDS educational campaign on the Albion Street (AIDS) Centre and the AIDS Hotline.

The national educational programme on the acquired immunodeficiency syndrome (AIDS) caused a dramatic increase in the number of heterosexual persons who presented for human immunodeficiency virus (HIV) antibody testing at the Albion Street (AIDS) Centre. There was also a marked increase in the number of intravenous drugs abusers who presented, although the proportion of this high-risk group that has been tested remains low. There was no increase in the number of homosexual men who presented for testing. The increase in the number of telephone calls that were received by the Centre's AIDS Hotline was due to an interest in HIV-antibody testing, rather than an interest in information about safer sexual practices. The campaign was seen to have achieved its primary objective, namely, to alert sexually-active persons of the potential spread of the virus from the high-risk groups. However, it is clear that future educational campaigns need to target specific high-risk groups such as intravenous drug abusers.

Acquired Immunodeficiency Syndrome↗

PubMed2004

Distance communication transfer of HIV prevention interventions to service providers.

Most acquired immunodeficiency syndrome (AIDS) service providers are in countries with little access to scientific developments relevant to their programs. It is critical to transfer advances from the scientific arena to service providers on a global scale. Human immunodeficiency virus (HIV) prevention organizations in 78 countries were randomized to receive either a control condition or a technology transfer condition with an interactive distance learning computer training curriculum and individualized distance consultation. Of 42 nongovernmental organizations in the technology transfer condition, 29 adopted the science-based program in their communities or trained other agencies to also use it. Advanced communication technologies can create a cost-effective infrastructure to disseminate new intervention models to service providers worldwide.

Communication↗