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PubMed2002

Rapid public health interventions in response to an outbreak of syphilis in Los Angeles.

BACKGROUND: Despite national ambitions to eliminate syphilis, occasional outbreaks continue to occur in many areas of the United States. GOAL: The goal of the study was to describe and evaluate the public health interventions in response to an outbreak of syphilis in Los Angeles County among men who have sex with men. STUDY DESIGN: Reported cases of primary, secondary, and early latent syphilis that occurred during an outbreak period from December 1999 to September 2000 were included in the study. The outbreak components of provider awareness, active surveillance, community-based organization recruitment, media campaign, community-outreach education and screening, and a correctional facility intervention were described. Screening results were reviewed, sexually transmitted disease (STD) hotline calls were counted, and a street-intercept survey was conducted. RESULTS: A multifaceted outbreak response was initiated in March 2000. Of the 89 outbreak cases identified, 40% were detected by HIV/AIDS early intervention providers and 26% by private clinicians or health maintenance organizations. Other case identification sources included public STD clinics (10%), STD program case-management contacts (7%), mobile van screening (7%), and correctional facility screening (10%). Screening at high-risk venues detected a syphilis prevalence of <1% and an HIV prevalence of 6%. Weekly calls to the STD hotline increased 600% during the outbreak, and 80% of surveyed individuals cited the media as the source of their awareness of syphilis. CONCLUSIONS: A multifaceted outbreak response was launched to react to an outbreak of syphilis among men who have sex with men. Prompt provider awareness and a preexisting network of HIV/AIDS providers aided case detection. Although the effectiveness of the response could not be scientifically determined, the diverse components of the response were associated with a faster decline in the outbreak than would have been expected. After 3 months, 89 cases had been identified. Outbreak preparedness should include a focus on communities of men who have sex with men, because the reintroduction of syphilis in this population may threaten national efforts toward syphilis elimination.

Adult↗

PubMedDate not supplied

Teaching inner-city mothers about family planning and prenatal and pediatric services.

One hundred thirty-five young, black, inner-city, pregnant women assessed the usefulness of a videotape designed by community health nurses to increase the self-care practices of low-income minority women with regard to their prenatal, pediatric, and family planning health needs. Seventy percent of the women rated as very useful information on the availability of health care and the protocols of public health clinics. The women also stated that they would tell others about public health care services and intended to make use of these services themselves as a result of viewing the videotape. The viewers' responses help clarify the preferred modality, content, and length of patient education for medically and socioeconomically high-risk pregnant women who tend to underuse preventive and primary health care.

Child Health Services↗

PubMed1994

Continuing medical education about AIDS--a needs assessment.

The incidence of the acquired immunodeficiency syndrome (AIDS) among Latinos and African Americans nationally and in Los Angeles has risen substantially. No data exist to indicate which physicians (or groups of physicians) provide care to these groups, however. To better plan AIDS educational programs, efforts were made to identify those physicians whose offices were located in areas with high proportions of nonwhites. Many physicians in these areas--30% of all office-based primary care physicians in Los Angeles--were found to be graduates of international medical schools. A survey of a stratified random sample of international medical graduates revealed that compared with a random sample of United States medical graduates, they had a greater proportion of nonwhite patients, often of an ethnicity similar to theirs; practiced in areas with a greater proportion of Asians and lower family incomes; had fewer patients infected with the immunodeficiency virus (HIV) in their practices; and were more avoidant of such patients. As the incidence of HIV infection increases among minority groups, means need to be developed to ensure their access to counseling and screening, as well as treatment with the latest available agents. Options include imaginative and engaging approaches to continuing medical education for all physicians and the creation of separate public sector infrastructures to meet the HIV-related needs of these communities.

Acquired Immunodeficiency Syndrome↗

PubMed2006

Community response to intermittent preventive treatment delivered to infants (IPTi) through the EPI system in Manhiça, Mozambique.

OBJECTIVE: To describe attitudes to the expanded programme on immunization (EPI) and intermittent preventive treatment in infants (IPTi), and perceptions of the relationship between them. In particular, whether the introduction of IPTi negatively affects community attitudes to, or use of, EPI; or, conversely, whether and if so how, the concurrent delivery of IPTi and immunization influences perceptions of IPTi. METHODS: Anthropological study carried out in the context of a trial of IPTi with sulphadoxine-pyrimethamine delivered alongside routine EPI vaccinations. We used open in-depth interviews, semi-structured interviews and participant observation, conducted in both community and clinic settings. RESULTS: IPTi was generally acceptable, in spite of initial resistance. Perceived negative aspects of IPTi did not affect perceptions of EPI, and IPTi was not misinterpreted as immunization against malaria, leading to a reduction of other preventive measures or delay in treatment seeking. Initial resistance was related more to the trial than to IPTi per se, but both rejection and acceptance were embedded in a complex constellation of local and wider contextual factors. CONCLUSIONS: IPTi delivered together with EPI was generally accepted after initial rejection. The factors that led to this rejection were largely local and trial related, but they did resonate with much wider cultural themes (rumours about research and health interventions, gender inequality and health-related decision making). The prior acceptance and routine administration of EPI played a key role in the acceptance of IPTi in this community. However, more studies, in different social and cultural settings and using different drugs and regimens, are needed before generalizations can be made. Although trial settings are different from actual implementation, it is necessary to study acceptability before implementation in order to anticipate problems and design information campaigns to ensure maximum community acceptance.

Adolescent↗

PubMed1997

Involving the private sector in improving obstetric care, Anambra State, Nigeria. The Enugu PMM Team.

PRELIMINARY STUDIES: Of 11 facilities providing obstetric services in the Njikoka Local Government Area, four were private, for-profit institutions. Focus group discussions in seven communities revealed a preference for private facilities due to flexible payment schedules, proximity, reliable availability of a medical doctor and poor quality government services. Each of the private facilities had one doctor and one midwife and the bulk of patient care was performed by health aides with no formal midwifery training. INTERVENTIONS: In 1992, 15 aides from the private facilities were trained in the recognition and management of obstetric complications. The training consisted of one week of classroom instruction and two weeks of practical training in local missionary hospitals. RESULTS: Improvements were assessed by a written test. The percent of trainees obtaining a passing test mark increased from 33% (pre-training) to 61% (post-classroom) to 77% (post-practicum). COSTS: The cost of this intervention was approximately US $18,000. CONCLUSIONS: Auxiliaries' skills can be improved with classroom and practical training. The involvement of private sector institutions is important where they provide a substantial proportion of emergency obstetric services. However, maintaining improvements requires sustained efforts.

Allied Health Personnel↗

PubMed1999

Reaching and enrolling drug users for HIV prevention: a multi-site analysis.

Since 1994, several sites have participated in a NIDA Cooperative Agreement for AIDS Community-based Outreach/Intervention Research Program to examine rates of HIV risk behaviors and evaluate HIV risk reduction interventions among out-of-treatment drug injection and crack cocaine and heroin smokers. We studied the process and outcome of community outreach for recruitment of drug users in AIDS research and education projects in three metropolitan areas: St. Louis, MO; San Antonio, TX, and Durham and Wake Counties, NC. There were two primary areas of focus: (1) the level of accuracy among community health outreach workers (CHOWs) in identifying potentially eligible persons for HIV prevention, and (2) overall effectiveness in recruiting and enrolling persons in formal assessment and intervention studies. We found cross-site and within-site differences in levels of accuracy and in recruitment and enrollment yields. Drug users who had never been in treatment and drug users who had never been tested for HIV infection were underrepresented at all sites. We discuss the factors which may have contributed to cross-site and within-site differences. The findings suggest a need for continued study, refinement, and evaluation of community outreach strategies in order to enroll a broad spectrum of vulnerable groups in HIV prevention activities.

Acquired Immunodeficiency Syndrome↗

PubMedDate not supplied

Community implementation of home care palliative care education.

PURPOSE: The purpose of this National Cancer Institute-funded training project was to improve end-of-life care agencies through implementation of a palliative care curriculum. The Home Care Outreach for Palliative Care Education (HOPE) program was designed to improve the knowledge and skills of home healthcare professionals who provide care to the terminally ill and their families at home. DESCRIPTION OF PROGRAM: A five-module palliative care education curriculum was designed and implemented in five home care agencies in the Los Angeles area. One hundred twenty-five nurses and 28 home health aides participated. The methods of data collection included two written surveys conducted before and after intervention, chart audit tool and a case study analysis form. RESULTS: The precourse data revealed deficiencies in home-care agency staff knowledge in and clinical aspects of end-of-life care. Regarding agency nurses' knowledge on end-of-life issues, the overall percentage scores from preeducation to posteducation rose from 84.6% to 89.0% (P =.0001). Participants rated the education program as extremely valuable for the home care agency staff. CLINICAL IMPLICATIONS: As home care will likely continue to be a primary setting for end-of-life healthcare, improvement of palliative care education in home health agencies is needed. The HOPE project provided insight and experience in the education of nonhospice home care staff in end-of-life care. Participant responses and evaluations indicated that end-of-life care education can improve the quality of care provided by home health agencies. Finally, this education program may result in a heightened awareness of hospice care and, although not objectively quantified, perhaps an increase in referrals to hospice.

Health Services Research↗

PubMed1996

AIDS knowledge and high-risk behaviour in the chronic mentally ill.

OBJECTIVE: To ascertain the degree of HIV-risk knowledge among patients attending a downtown program and to identify the extent of high-risk behaviour for HIV infection. METHOD: A total of 151 patients were selected at the Calgary Community Mental Health Clinic (N = 110) and the nearby Self Help Association (N = 41). Most of the subjects were being treated for either schizophrenia (n = 69), bipolar disorder (n = 37), or unipolar mood disorder (n = 35). Questionnaires included a 10-item instrument that assessed subjects' knowledge about HIV or AIDS and another 10-item tool that assessed the high-risk situations patients might have encountered over the past month or past year. RESULTS: Although the percentage of subjects erring on questions about AIDS knowledge was smaller when compared with previous studies, a significant number of subjects believed that one could acquire AIDS by donating blood, and 25% did not think that having only one unsafe sexual contact would make them vulnerable to HIV infection. At least 50% of the participants have had sex with at least one partner in the past year, and 33% of the participants indicated that they would not insist that they or their partners wear a condom. CONCLUSIONS: This Canadian study confirms the need for psychiatrists and mental health workers to continue to explore high-risk behaviour in the chronic mentally ill population and to further educate these patients through the development of prevention and risk-reduction strategies.

Acquired Immunodeficiency Syndrome↗

PubMed1996

AIDS prevention training for pharmacy workers in Mexico City.

Mexican pharmacies play an important adjunct health care role in sexually transmitted disease prevention and treatment. In light of the rapid spread of the AIDS pandemic, research was initiated in 1989 to investigate the feasibility of pharmacies assisting in AIDS and STD prevention and control through community education and condom promotion. This study was implemented in three stages: a needs assessment, development of a training course and complementary materials, and an evaluation of the course and materials. The instruments used in the needs assessment were a KAP questionnaire and 'mystery shopper' visits to pharmacies. The evaluation design utilized pre- and post-tests, condom sales tracking and 'mystery shopper' visits. The needs assessment found that pharmacy employees have some basic knowledge about AIDS and STDs, but lack important information and do not communicate effectively with clients in spite of client interest in these topics. Pharmacy workers expressed great in learning more about AIDS and STDs. The evaluation of the intensive 8-hour course and supporting materials showed that, when given together, the course and materials increased short term knowledge about AIDS and condom use. However, the interventions were less successful in achieving longer term information retention, transfer of knowledge to clients or in influencing condom sales. Adjustments in the training course content and in participant recruitment strategies are recommended.

Acquired Immunodeficiency Syndrome↗

PubMedDate not supplied

The use of formal prior directives among patients with HIV-related diseases.

OBJECTIVE: To examine the knowledge of, counseling about, and use of prior directives among patients with HIV-related disease. DESIGN: Cross-sectional survey with personal interviews that was part of the evaluation of a multi-site AIDS Health Services Program. SETTING: Outpatient clinics and AIDS community-based organizations. PATIENTS/PARTICIPANTS: To be eligible for the survey, subjects had to be at least 18 years of age and enrolled in the AIDS Health Services Program for at least one month. 1,031 clients were interviewed in nine communities. MEASUREMENTS AND MAIN RESULTS: Of those surveyed, 61% had thought a moderate or great amount about naming a proxy for health care decisions. The majority (68%) of the patients knew about prior directives, yet only 35% had been counseled and only 28% had a prior directive. Of those counseled, physicians had counseled only 11% (38/359). Gay/bisexual men were more likely to have been counseled and to have executed a prior directive than were others. Counseling was associated with having obtained a prior directive. Counseled subjects were 3.5 times more likely to have obtained a prior directive than were those not counseled. CONCLUSIONS: A gap exists between subjects' knowledge and implementation of prior directives. To help bridge this gap, the authors recommend that physicians not only attend to the technical aspects of patient care, but also determine patient values concerning life-sustaining therapy and counsel patients on prior directives.

Advance Directives↗

PubMed1996

Zidovudine use to reduce perinatal HIV type 1 transmission in an urban medical center.

OBJECTIVE: To evaluate whether zidovudine treatment was accepted and used by pregnant women subsequent to the release of the results of a multicenter, randomized, placebo-controlled trial (AIDS Clinical Trial Group [ACTG] Protocol 076) that showed that zidovudine significantly reduced maternal-infant human immunodeficiency virus (HIV) type 1 transmission. DESIGN: Prospective study. SETTING: A community hospital with an integrated, multidisciplinary HIV-dedicated program located in an impoverished, HIV-endemic urban setting. PARTICIPANTS: All HIV-infected pregnant women identified after the release of the ACTG 076 results who were offered zidovudine therapy to reduce maternal-infant transmission. RESULTS: Only 49 of the 125 HIV-infected pregnant women delivering at our site during this study period were identified prenatally. Perinatal zidovudine therapy was chosen by 37 (75%) of 49 women. Women refusing zidovudine were more likely to report injection drug use as their HIV risk factor and to continue to use drugs during their pregnancy. Of women choosing zidovudine and delivering, 24 of 36 received all components of their elected therapy. The intrapartum dose was missed by 12 women, 4 of whom also missed their prescribed prenatal oral therapy. Lack of adherence to chosen therapy was associated with continued cocaine use during pregnancy. CONCLUSIONS: Zidovudine therapy to interrupt vertical transmission of HIV was not widely used by these HIV-infected pregnant women. Further studies evaluating factors affecting the acceptance and use of recently published public health recommendations are needed.

Adolescent↗

PubMedDate not supplied

Responding to racial and ethnic disparities in use of HIV drugs: analysis of state policies.

OBJECTIVES: The objectives of this study were to assess racial/ethnic trends in surveillance data in four states--California, New York, Florida and Texas, identify structural barriers to and facilitators of access to HIV pharmaceuticals by individuals in Medicaid and the AIDS Drug Assistance Program (ADAP), and identify treatment education and outreach efforts responding to the needs of ethnic minority HIV patients. METHODS: State surveillance and claims data were used to assess trends by race/ethnicity in AIDS cases and mortality as well as participation rates in Medicaid and ADAP. Key informant interviews with state program administrators and local clinic-based benefit eligibility workers were used to identify social and policy barriers to and facilitators of access to HIV drugs and state strategies for overcoming racial/ethnic disparities. RESULTS: Racial/ethnic disparities in the reduction of AIDS-related mortality were identified in three of the four states studied. Policy barriers included Medicaid requirements for legal immigration status and residency, limits on Medicaid eligibility based on disability requirements, and state-imposed income and benefit limits on ADAP. Social barriers to accessing AIDS medications included lack of information, distrust of government, and HIV-related stigma. State strategies for overcoming disparities included contracting with community-based organizations for treatment education and outreach, the use of regional minority coordinators, and public information campaigns. CONCLUSIONS: State policies play a significant role in determining access to HIV drugs, and state policies can be used to reduce racial/ethnic disparities in pharmaceutical access. Overall, eliminating racial/ethnic disparities in access to HIV pharmaceuticals appears to be an achievable goal.

Acquired Immunodeficiency Syndrome↗

PubMed1989

Clinical approaches to families in early intervention.

Clinical approaches to families with infants in early intervention programs require more sophisticated and individualized plans that have been traditionally available. Clinicians in early intervention programs, including those trained in child-oriented disciplines, will increasingly be expected to develop comprehensive family focused interventions. Empirical findings support the legislative mandate of PL99-457 in requiring that families have an active role in specifying the intervention services they require. In addition, the broader concept of risk that now includes multi-problem families also complicates the job of the early interventionist. As parents must learn to adapt to their infant's unique characteristics, early interventionists must adapt to the unique characteristics of each family with whom they are involved. To aid in this process, we apply the concept of a working alliance to the aspect of the parent-professional relationship that early interventionists must develop and maintain in providing empathic and individualized care to families in early intervention. Sensitivity to the families' unique characteristics, responsitivity to their concerns, positive connotation of parents' and infants' behavior, a nonjudgmental attitude, and a willingness to monitor one's feelings and responses elicited by the family are clinical principles essential for developing and maintaining the working alliance.

Child Guidance Clinics↗

PubMed1998

Childrens Hospital Los Angeles: a model of integrated care for HIV-positive and very high-risk youth.

Childrens Hospital Los Angeles (CHLA) provides an integrated care model for youth with and at high risk for human immunodeficiency virus (HIV) infection, through a grant from the Special Projects of National Significance Program, HIV/acquired immunodeficiency syndrome (AIDS) Bureau, Health Resources and Services Administration. The project has provided outreach to 8400 youth at risk and has provided clinical services to 296 young men (16.6% HIV positive) and 352 young women (9.1% HIV positive). Situated within the Division of Adolescent Medicine at Childrens Hospital Los Angeles, the project consists of a general medical clinic for youth along with psychosocial services including case management, counseling, and related ancillary services. A key part of the model is to provide health services within a general medical clinic for youth where participation in the clinic does not serve to identify a youth to his or her peers in the waiting room as having HIV. Another key part of the model is to provide extensive outreach within the community including contacts at bars and social clubs where high-risk youth congregate, on the street, and through the social networks of youth already identified as having HIV who participate in the CHLA clinics. In the last 2 years of the program, the peer outreach component has been strengthened and peer support activities have also been implemented. The program also has developed a Computer-Assisted Adolescent Referral System (CAARS), available on diskette and on the Internet, for the referral of youth to services in the Hollywood area.

Acquired Immunodeficiency Syndrome↗

PubMed1995

The clinical competency of community health workers in the eastern highlands province of Papua New Guinea.

A case study of the clinical competency of community health workers employed in the Eastern Highlands Province of Papua New Guinea was conducted in March 1993. Of the 79 who graduated from the Onamuga Community Health Worker Training School between 1989 and 1992, only 24 were currently employed in the province. Current knowledge and clinical competency were compared with results on completion of basic community health worker training. Results showed that 22 of the 24 maintained their knowledge competency, and 15 maintained clinical competency. It was found that those community health workers (CHWs) employed at a health subcentre use 40% to 50% of their skills, whilst those at a district health centre or provincial hospital use only 20% to 30% of their skills. Only 8% of the CHWs studied used all the skills obtained in their basic training. This study indicates that the CHW is being viewed by some health managers as a replacement for the nurse aide. If CHWs' skills are to be maintained, certainly good supervision, inservice training and adequate logistic support are needed, but so also is a change in management thinking. The CHW has been trained specifically to improve the access to essential primary health care services of people living in rural areas, especially in preventive and maternal and child health care. If in practice the CHW is not given the opportunity to practise and hence maintain these skills, the whole logic of the CHW training scheme will need to be reexamined.

Adult↗

PubMed1998

Strategies for reaching Asian Americans with health information.

INTRODUCTION: Cultural, linguistic, and economic barriers place many Asian Americans in jeopardy of missing opportunities for disease prevention, early diagnosis, prompt treatment, and participation in clinical trials. One way to learn how to address these barriers is through the development of a demonstration health education and prevention program focused on an indicator disease such as cancer. METHODS: In 1994, the University of California, San Diego (UCSD) Cancer Center began a highly focused cancer education program. Staffing was done with a variety of bicultural and bilingual undergraduates recruited from local colleges and trained to work as community health educators. Asian grocery stores were selected as optimal educational sites. Adaptation of sheltered English teaching techniques and hands-on teaching aids helped to overcome language and educational barriers. The educational intervention was evaluated using unobtrusive measures. RESULTS: With the volunteers' help, culturally sensitive means to disseminate information on cancer were evaluated. A variety of approaches evolved that effectively bridged many communication barriers. Fear of cancer itself, belief that thinking about cancer could provoke the onset of the disease, and financial barriers to care proved to be just as formidable barriers to cancer education in this ethnic group as they are in others. Using student volunteers and donated store space, this educational program was conducted with minimal expense. CONCLUSION: Reaching this population with the help of ethnically and linguistically compatible students was effective, but the barriers they faced when trying to connect with their potential audience were still considerable. Rigorous evaluation of the strategies used in this intervention is warranted.

Asian↗

PubMed2003

Information needs in the management of osteoporosis in family practice: an illustration of the failure of the current guideline implementation process.

The objectives of this study were to determine information needs of family physicians around issues in the management of osteoporosis and preferences for dissemination of this information. A mailed survey was sent to a stratified random sample of 1000 family physicians in Ontario in May 2001. Female physicians and those practicing in rural communities were over-sampled from the College of Family Physicians' database. Among the 505 respondents, 364 were still practicing (182 males and 182 females) and completed the full questionnaire. There were no statistically significant differences in responses by sex or region of practice. Over 80% of family physicians wanted to be more informed about bone density testing and the pharmacological and non-pharmacological management of osteoporosis. The presence of risk factors was one of the most influential factors (72%) for ordering bone density testing. Information in peer-reviewed journals was thought to be the most credible, with 80% rating the CMAJ as very credible compared to 47% for the Osteoporosis Society of Canada (OSC). Sixty-two percent found the OSC guidelines (1996) to be useful even though much of that information is now out of date. Almost 70% had not read the more recently published treatment guidelines from the Ontario Program for Optimal Therapeutics (2000). Over 80% were interested in a decision aid, which incorporates information on risk factors, fracture risk and a treatment algorithm. The perceived need and the lack of availability of clinically useful information on osteoporosis for the family practice setting highlights the failure of the current guideline implementation process and provides insight into where the process has to be improved.

Adult↗

PubMed1997

Worksite characteristics and changes in worksite tobacco-control initiatives. Results from the COMMIT study.

Few studies have prospectively examined the characteristics associated with worksite adoption of tobacco-control initiatives. Data were collected as part of the Community Intervention Trial (COMMIT) for Smoking Cessation, which conducted interventions in 11 communities. This smoking cessation intervention was based on community organization principles and delivered through multiple community channels, including worksites, health care providers, the media, and cessation resources. This article reports results from telephone interviews of intervention community worksites having 50 or more employees, conducted at baseline and the end of the intervention period. Among worksites that responded to both baseline and final surveys, 83% had not adopted a smoke-free policy at baseline, and 61% did not offer any cessation aid or quitting resources at baseline. By the final survey, 34% of those with no smoking ban at baseline had become smoke-free, and 36% of those offering no cessation assistance at baseline were offering cessation resources at the follow-up. The prevalence of policy adoption was higher among worksites employing more female employees and offering other health-promotion activities; manufacturing businesses were significantly less likely than businesses other than service and wholesale/retail businesses to adopt policies. Adoption of cessation programs was significantly more likely among worksites employing 100 to 249 workers, compared with those employing 50 to 99 workers; those predominantly employing men; those offering other types of health-promotion activities; and those with a higher rate of turnover. These results provide important information about the characteristics of worksites likely to engage in tobacco-control efforts. Health educators and others may choose to target those worksites most ready for adoption of tobacco control policies and programs, as indicated by these findings.

Adult↗