Thought processes associated with reluctance in gay men to be tested for HIV.

This study explored the thought processes that are associated with reluctance in gay men to be tested for HIV antibodies. The sample comprised 97 men who had not been tested for at least four years; 69 had never been tested. They were asked to imagine that someone had suggested that they be tested very soon and to identify, from the list provided, any negative thoughts prompted by this suggestion. The most commonly reported thoughts were that testing was unnecessary because risks had not been taken, that it was unnecessary because there were no symptoms, and that there was no urgency to be tested. Data were explored by means of factor analysis and comparisons across subgroups differing in risk level. The results are interpreted as indicating the use of rationalizations to buttress a decision not to be tested, the powerful influence on HIV decision-making exerted by salient perceptible features, and the 'status quo bias'. Techniques that could be used to encourage testing in gay men are discussed.

The impact of Internet use for weight loss.

With rising rates of obesity and obesity-related health problems, finding additional means to help reduce obesity is critical. This review examined the impact of the Internet as a medium to deliver weight loss programs. Specifically, the review examined the public's interest, the availability and the known efficacy of Internet-based weight loss programs. Findings showed that the general public is turning to the Internet for diet and fitness information and has reported that information they found online has impacted their behaviour. Little is known about who is interested in using the Internet for weight loss and what their experiences have been. The programs most readily available to the general consumer tend to vary widely in quality, with few efficacy studies. However, researchers have shown that efficacious programs have been delivered via the Internet. Successful online programs included a structured approach to modifying energy balance, the use of cognitive-behavioural strategies such as self-monitoring, and individualized feedback and support. Implications include developing strategies to increase distribution of programs with known efficacy, determining the applicability of effective programs for diverse audiences, conducting media literacy education for the general public, and continued research into understanding who may be best served by online weight loss programming.

Spontaneous comparisons with others in gay men's judgements of HIV risk.

In studies on 'unrealistic optimism' (UO), when people are asked questions designed to make them compare their risk of experiencing an undesirable event with that of the average person, they tend to respond that their risk is lower. This study investigated whether comparisons of own and others' risk also occur spontaneously, unprovoked by such questions. Gay men uninfected with HIV (n=50) were asked to think aloud about their risk of becoming infected; their comments were audiotaped and analysed. Over half the men added comments relating to others' risk. The phrasing of these comments and the reported basis for them are described. The men represented others' risk as relatively high, own risk as relatively low. In the case of one-third of the men, it seemed possible to be confident that a comparison was being made. The findings suggest that comparisons of own and others' risk do occur spontaneously and that, while the judgements made in UO studies do not capture all the characteristics of those made spontaneously, they resemble them in important ways.

Unrealistic optimism about becoming infected with HIV: different causes in different populations.

People tend to believe that their chance of experiencing undesirable events is lower and their chance of experiencing desirable events is higher than that of the average person like them. Two explanatory models of such 'unrealistic optimism' (UO) have been proposed: While the motivational account holds that UO serves the function of bringing comfort, the cognitive account holds that UO serves no particular function, being simply a by-product of normal cognitive strategies. UO for HIV infection was studied in samples of uninfected students (Study 1, n = 68) and gay men (Study 2, n = 63). In each case, participants rated either their relative likelihood of becoming infected (negative valence condition) or their relative likelihood of remaining uninfected (positive valence condition). As predicted, in Study 1 UO was greater where valence was negative and in Study 2 valence had no effect. The findings suggest that the students' UO is better explained by the motivational account, while the gay men's UO is better explained by the cognitive account. Implications for AIDS education are discussed.

Development of an expert system knowledge base: a novel approach to promote guideline congruent asthma care.

Existing guidelines for the clinical management of asthma provide a good framework for such tasks as diagnosing asthma, determining severity, and prescribing pharmacological treatment. Guidance is less explicit, however, about establishing a patient-provider partnership and overcoming barriers to asthma management by patients in a way that can be easily adopted in clinical practice. We report herein the first developmental phase of the "Stop Asthma" expert system. We describe the establishment of a knowledge base related to both the clinical management of asthma and the enhancement of patient and family self-management (including environmental management). The resultant knowledge base comprises 142 multilayered decision rules that describe clinical and behavioral management in three domains: 1) determination of asthma severity and control; 2) pharmacotherapy, including prescription of medicine for chronic maintenance, acute exacerbation, exercise pretreatment, and rhinitis relief; and 3) patient self-management, including the process of intervening to facilitate the patient's asthma medication management, environmental control, and well-visit scheduling. The knowledge base provides a systematic and accessible approach for intervening with family asthma-related behaviors.

Explaining gay men's unrealistic optimism about becoming infected with HIV.

Among the self-justifications that gay men use when deciding to have unprotected intercourse is the thought that they are at less risk than most gay men. Two explanatory models of such 'unrealistic optimism' (UO) have been proposed: while the motivational account holds that UO serves the function of bringing comfort, the cognitive account holds that UO serves no particular function, being simply a by-product of normal cognitive strategies. This study tested the prediction, derived from the motivational account, that highlighting the salience of the self-other comparison should increase UO. Gay men uninfected with HIV (n=122) estimated both their own risk of contracting various health problems--among them, becoming infected with HIV--and that of the average gay man. The purported aim of collecting the data was varied, so as to either make the self-other comparison central to the aim or render one of the two types of estimate irrelevant to the aim. No effect on UO was found. It seems that the cognitive account provides a better explanation than does the motivational account of at least that form of UO measured in this study. Implications for AIDS education are discussed.

'I'm less at risk than most guys': gay men's unrealistic optimism about becoming infected with HIV.

Among the self-justifications that gay men use when engaging in high-risk sex is the thought that they are less at risk than most gay men. Two explanatory models of such 'unrealistic optimism' (UO) have been proposed: while the motivational account holds that UO arises because it serves the function of bringing comfort, the cognitive account holds that UO serves no particular function, being simply a by-product of normal cognitive strategies. This study investigated predictions derived from the motivational account. Gay men uninfected with HIV (n = 88) answered two test questions, requiring them to estimate, respectively, their own risk of becoming infected and that of the average gay man. The questions were presented in the two possible orders, and were either separated or not separated by unrelated filler material. The great majority of the men (89%) exhibited UO. Neither question order nor the interpolation of filler material affected responses to either test question. The results were inconsistent with the motivational account, but explicable in terms of the cognitive account. It seems that the cognitive account provides the better explanation of at least that form of UO measured in this study. Implications for AIDS educators are discussed.

The effects of mood states on the AIDS-related judgements of gay men.

In two studies, the effects of induced mood on the AIDS-related judgements of gay men were investigated. Participants were induced into a positive, neutral, or negative mood by recall of affect-laden autobiographical memories; they then made AIDS-related judgements. In Study 1 (n=30), the men indicated their level of agreement with statements expressing optimism about the efficacy of antiretroviral treatments for HIV/AIDS. Those induced into a positive mood indicated stronger agreement than did those induced into a neutral or negative mood. In Study 2 (n=83), participants read brief descriptions of men they did not know and estimated the likelihood that they were HIV-infected. Each sketch highlighted one characteristic of the man described. There were two versions of each sketch (e.g., the versions of the sketch highlighting intelligence described the man either as very intelligent or as very unintelligent), given to different participants. Stereotype use was inferred if significantly different estimates were given for the two versions of a sketch. Reliance on stereotypes was found most often in the positive mood condition and least often in the negative mood condition. The findings are consistent with, and suggest explanations for, earlier correlational evidence that, in gay men of the age group studied, sexual risk-taking is associated with a positive mood. Suggestions are made for how AIDS educators might address the contributions of mood states to sexual risk-taking.

Evaluation of interventions for gay men: two desiderata.

This paper was presented in a session at the AIDS Impact conference devoted to a debate on the methods that should be used to evaluate educational interventions. The paper highlights two desiderata for evaluation of interventions directed at gay men. First, the view is presented that there is no acceptable substitute for assessing the effect of an intervention on gay men's sexual behaviour (rather than, for example, their AIDS-related attitudes or beliefs). This view is justified in terms of (a) the differences that exist between AIDS-related thinking in the cold light of day and during actual sexual encounters; and (b) the often faulty nature of intuitions about the factors that contribute to sexual risk-taking and the ways in which it might be reduced. Second, it is argued that the randomized control study design represents the best means for ensuring that interventions will be as effective as possible. Criticisms which have been made of this design are discussed and the conclusion drawn that they do not amount to a strong case against it.

"I will start treatment when I think the time is right": HIV-positive gay men talk about their decision not to access antiretroviral therapy.

In a qualitative study, 20 HIV-infected Australian gay men were interviewed about their decision not to access antiretroviral drug therapy. The main reasons given for the decision were fear of side effects; fear of long-term damage to body organs; the inconvenience of the treatment regimens; belief that the regimen's demands would be a threat to morale; and belief that there was no reason to start therapy in the absence of AIDS-related symptoms. Actions taken by the men to monitor and maintain their health included seeing a doctor regularly; having regular T-cell and viral load tests; and trying to maintain a positive outlook by not letting HIV/AIDS 'take over' their lives. Almost half the men considered they had been subjected to unreasonable pressure to access therapy and there was considerable pride at having resisted this pressure. The findings suggest that the men disagreed with the biomedical model for managing HIV/AIDS only on the question of if and when to access therapy. They also suggest that underlying the men's dissent from the biomedical model was a different mode of thinking than is required by the model: while the model demands thinking that is abstract, the men focused strongly on factors close to the 'here and now' of immediate experience. The practical implications of the findings are explored.

Combined genitourinary prolapse repair and prophylactic tension-free vaginal tape in women with severe prolapse and occult stress urinary incontinence: preliminary results.

OBJECTIVES: Continent patients with a positive stress test demonstrated on repositioning of severe genitourinary prolapse are considered to be at high risk of developing postoperative symptomatic stress urinary incontinence (SUI). Our aim was to evaluate in a prospective study whether a prophylactic, tension-free vaginal tape (TVT) procedure, performed during prolapse repair, may prevent the development of postoperative SUI in these women. METHODS: Thirty consecutive, clinically continent women (mean age 64.5 +/- 9.04 years) with severe genitourinary prolapse and occult SUI were prospectively enrolled. Occult SUI was defined as a positive stress test with repositioning of the prolapse during the preoperative urodynamic studies. All patients had urethral hypermobility; none had intrinsic sphincter deficiency. In addition to genitourinary prolapse repair, these patients underwent concomitant TVT to prevent postoperative SUI. Patients were followed up for at least 1 year. Repeated urodynamic studies were performed at 3 to 6 months postoperatively. The main outcome measures were postoperative SUI, persistent or de novo detrusor instability, and recurrence of prolapse. RESULTS: The mean duration of follow-up was 14.25 +/- 3.08 months (range 12 to 24). None of the patients developed postoperative symptomatic SUI. However, three asymptomatic patients (10%) had a positive stress test during their postoperative urodynamic evaluation. Nine patients (30%) had detrusor instability before surgery, which persisted in six (66%) postoperatively. Postoperative de novo detrusor instability was diagnosed in four other patients (13.33%). None of the patients had recurrent urogenital prolapse, nor did they have clinical evidence of bladder outlet obstruction. CONCLUSIONS: The preliminary results of TVT as a prophylactic procedure in clinically continent women with severe prolapse and occult SUI are encouraging. Long-term follow-up is required to confirm the durability of these results.

Importance of health education research to health education.

OBJECTIVE: To focus on the benefits and importance of research to the practice of health education. METHODS: The paper discussed the potential of quality research as well as the barriers that keep health educators from using, applying, and sharing their work. RESULTS: The basic challenges health educators face in translating their research into practice relate to: becoming well-versed in the science base and previous lessons learned; collaborating effectively; and passing on knowledge by mentoring. CONCLUSIONS: To move forward, health educators need to organize their knowledge and make it accessible. This includes explicit and tacit knowledge, work in progress, and a coordinated research agenda. Finally, health educators need to be flexible so they can enable future research needs.

Gay men's estimates of the likelihood of HIV transmission in sexual behaviours.

In 3 studies we recorded gay men's estimates of the likelihood that HIV would be transmitted in various sexual behaviours. In Study 1 (data collected 1993, n=92), the men were found to believe that transmissibility is very much greater than it actually is; that insertive unprotected anal intercourse (UAI) by an HIV-infected partner is made safer by withdrawal before ejaculation, and very much safer by withdrawal before either ejaculation or pre-ejaculation; that UAI is very much safer when an infected partner is receptive rather than insertive; that insertive oral sex by an infected partner is much less risky than even the safest variant of UAI; that HIV is less transmissible very early after infection than later on; and that risk accumulates over repeated acts of UAI less than it actually does. In Study 2 (data collected 1997/8, n=200), it was found that younger and older uninfected men generally gave similar estimates of transmissibility, but that infected men gave somewhat lower estimates than uninfected men; and that estimates were unaffected by asking the men to imagine that they themselves, rather than a hypothetical other gay man, were engaging in the behaviours. Comparison of the 1993 and 1997/8 results suggested that there had been some effect of an educational campaign warning of the dangers of withdrawal; however, there had been no effect either of a campaign warning of the dangers of receptive UAI by an infected partner, or of publicity given to the greater transmissibility of HIV shortly after infection. In Study 3 (data collected 1999, n=59), men induced into a positive mood were found to give lower estimates of transmissibility than either men induced into a neutral mood or men induced into a negative mood. It is argued that the results reveal the important contribution made to gay men's transmissibility estimates by cognitive strategies (such as the 'availability heuristic' and 'anchoring and adjustment') known to be general characteristics of human information-processing. Implications of the findings for AIDS education are discussed.

Online research to guide knowledge management planning.

The current paper describes the process and results of an effort to find a way to effectively manage and diffuse prevention knowledge. This study shows the role that today's communication technologies can play in ensuring collaboration and participation in both the design and use of a knowledge management system (KMS) for prevention research, practice and policy. In the context of this study, 'prevention research' includes primary through tertiary prevention efforts consistent with general applied public health research in the US. An online Delphi study was used to engage a set of prevention research constituencies in the design of a mechanism to enhance the potential for effective technology transfer. A three-round Delphi was conducted with 58 stakeholders and key informants involved in prevention: government-level policy makers, researchers and front-line practitioners. The study resulted in consensus on 34 functions and 32 output/content elements of a proposed web-based KMS called PreventionEffects.net. The paper also describes the implications of both the processes of development and the benefits of the proposed system for those interested in prevention.

Watch, Discover, Think, and Act: a model for patient education program development.

In this report we describe the development of the Watch, Discover, Think and Act asthma self-management computer program for inner-city children with asthma. The intervention focused on teaching two categories of behaviors--asthma specific behaviors such as taking preventive medication and self-regulatory processes such as monitoring symptoms and solving asthma problems. These asthma self-management behaviors were then linked with empirical and theoretical determinants such as skills and self-efficacy. We then further used behavioral science theory to develop methods such as role modeling and skill training linked to the determinants. We matched these theoretical methods to practical strategies within the computer simulation and created a culturally competent program for inner-city minority youth. Finally, we planned a program evaluation that linked program impact and outcomes to the theoretical assumptions on which the intervention was based.

Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children.

An interactive multimedia computer game to enhance self-management skills and thereby improve asthma outcomes in inner city children with asthma was evaluated. Subjects aged 6-17 were recruited from four pediatric practices and randomly assigned to the computer intervention condition or to the usual-care comparison. The main character in the game could match the subject on gender and ethnicity. Characteristics of the protagonist's asthma were tailored to be like those of the subject. Subjects played the computer game as part of regular asthma visits. Time between pre- and post-test varied from 4 to 15.6 months (mean, 7.6 months). Analysis of covariance, with pre-test scores, age, and asthma severity as covariates, found that the intervention was associated with fewer hospitalizations, better symptom scores, increased functional status, greater knowledge of asthma management, and better child self-management behavior for those in the intervention condition. Interactions with covariates were found and discussed in terms of variable efficacy of the intervention.

AIDS education for gay men: towards a more cognitive approach.

An approach to AIDS education is presented that focuses on the thinking processes which accompany gay men's decisions to engage in high-risk sex. It is proposed that: (1) at the time they are deciding to have high-risk sex, gay men generally engage in an 'internal dialogue' that justifies this decision to themselves; (2) the AIDS-related thinking underpinning such self-justifications can differ appreciably from the AIDS-related thinking that takes place outside the sexual context; and (3) AIDS education can profitably exploit this difference between 'heat of the moment' and 'cold light of day' thinking. Evidence supporting these proposals is drawn from studies in which gay men who had engaged in unprotected anal intercourse recalled the occasion concerned in detail, including any self-justifications they had used; and from controlled intervention studies, in which gay men who had engaged in unprotected anal intercourse were confronted with the thinking they had employed in the heat of the moment.

Does ICSI affect early serum beta-HCG in pregnancies achieved after IVF?

This study was conducted to compare early serum human chorionic gonadotrophin (HCG) concentrations in singleton pregnancies achieved after intracytoplasmic sperm injection (ICSI), with those achieved after conventional in-vitro fertilization (IVF). Early serum HCG, 14-16 days after embryo transfer, was analysed in 99 IVF pregnancies achieved after ICSI (group A), and compared to 105 conventional IVF pregnancies (group B). All women were treated at the IVF Unit, Lis Maternity Hospital. Records were studied retrospectively. The mean +/- SE serum HCG concentration on day 14 after embryo transfer in group A was 190.5 +/- 17.4 mIU/ml, compared to 195.7 +/- 14.03 mIU/ml in group B. HCG concentration 14 days after embryo transfer in both groups A and B was higher in women with mechanical factor than in couples with male factor infertility or unexplained infertility (246 +/- 31.4, 183.3 +/- 16.4, 177.98 +/- 14.3 mIU/ml respectively). On the 16th day after embryo transfer, the HCG concentration increased, and the difference between the groups was maintained. Only in the subgroup of unexplained infertility did we find a difference in concentrations of HCG between ICSI and conventional IVF: on the 16th day following embryo transfer in this group there was a significant difference in HCG concentrations (395. 8 +/- 21 and 545.6 +/- 45.7 respectively; P = 0.04). HCG concentrations did not differ overall in the conventional IVF pregnancies compared with those achieved by ICSI. However, a statistical difference in early serum HCG concentrations was found in relation to the aetiology of infertility.

The reasoning behind decisions not to take up antiretroviral therapy in Australians infected with HIV.

A substantial minority of HIV-infected Australians are not taking antiretroviral drugs. This study investigated the reasons behind their decision not to do so. Anyone who was HIV-infected but not taking antiretroviral drugs could participate. A self-administered, anonymous questionnaire was used, the principal recruitment method being through insertion of the questionnaire into gay community newspapers in Sydney and Melbourne. All respondents were asked questions covering demographics, previous AIDS-defining illnesses, T-cell and viral load monitoring, and previous use of antiretroviral drugs. In addition, respondents who had considered going on antiretroviral treatment, but then decided not to do so, were given a list of possible reasons for their decision and asked to indicate how much each played a role in their thinking. Of the 270 respondents, the great majority were gay men. One-eighth had experienced AIDS-defining illnesses. Two-thirds had recently had T-cell and viral load tests. One-third had taken antiretroviral drugs previously. Over two-thirds had considered antiretroviral therapy, most having given the matter quite some thought. Reasons for not taking up therapy did not differ greatly at different stages of HIV disease. The most common individual reason was fear of side effects. Important themes that emerged from factor analysis of the reasons data included distrust of conventional medical approaches to treatment, practical problems associated with taking antiretroviral drugs, unpleasant thoughts that being on therapy would evoke, and acceptance of the idea of dying. The findings can be used by doctors and counsellors to help patients clarify and evaluate their concerns about antiretroviral therapy.

Gay men's stereotypes about who is HIV infected: a further study.

Gay men's stereotypes about who is HIV-infected were investigated. Young uninfected (n=62), older uninfected (n=61), and infected (n=65) gay men read brief descriptions of men they did not know and estimated the likelihood that they were infected. Each description highlighted one characteristic of the man described. There were 3 versions of each sketch; the versions highlighting preferred sexual practice, for example, described the man as either preferring insertive anal intercourse, preferring receptive anal intercourse, or liking both equally. Results were largely the same for the 3 sample groups. For 6 of the 9 characteristics investigated--preferred haunts, preferred sexual practice, dress code, access to gay venues, occupation, and sexual orientation--significantly different estimates were given for the different versions. Results are discussed in relation to how AIDS education might counter the use by gay men of stereotypes to infer whether a given sex partner is infected. It is suggested that these stereotypes are likely to be present 'on line' (during actual sexual encounters), rather than 'off line' (in the cold light of day), thereby complicating the task of AIDS educators.