Hazardous and harmful use of alcohol and/or other drugs and health status among South African patients attending HIV clinics.

There is growing recognition of the influence of substance use, particularly alcohol use, on HIV disease progression. This study investigated how hazardous/harmful use of alcohol and drugs impacts the health status of 1503 patients attending HIV clinics. Of the sample, 37 % indicated hazardous/harmful drinking and 13 % indicated a drug problem. Hazardous/harmful use of alcohol and drugs was significantly related to health status, with participants using substances more likely to have TB-positive status (χ(2) = 4.30, p < 0.05), less likely to be on ARVs (χ(2) = 9.87, p < 0.05) and having lower CD4 counts (t = 4.01, p < 0.05). Structural equation modelling confirmed the centrality of hazardous/harmful use of alcohol as a direct and indirect determinant of disease progression. Based on these findings it is recommended that patients attending HIV clinics be routinely screened for problematic alcohol and/or drug use, with strong emphasis on ensuring ARV adherence in those with problematic alcohol use.

Readiness to adopt a performance measurement system for substance abuse treatment: Findings from the Service Quality Measures initiative.

BACKGROUND: A performance measurement system - the Service Quality Measures (SQM) initiative - has been developed to monitor the quality of South Africa (SA)'s substance abuse treatment services. Identifying factors associated with readiness to adopt this system may inform strategies to facilitate its robust implementation. OBJECTIVE: To examine factors associated with readiness to adopt a performance measurement system among SA substance abuse treatment providers. METHODS: We surveyed 81 treatment providers from 13 treatment sites in the Western Cape, SA. The survey examined awareness, resources, organisational climate, leadership support and readiness to adopt the SQM system. Regression analysis was used to identify factors associated with readiness to adopt this system. RESULTS: Readiness to adopt the SQM initiative was high (M=5.64, standard deviation 1.63). In bivariate analyses, caseload size (F=3.73 (degrees of freedom (df)=3.70), p=0.015), awareness (r=0.78, p<0.0001), leadership support (r=0.70, p<0.0001), resources (r=0.65, p<0.0001), openness to change (r=0.372, p=0.001), and external pressure to change were associated with readiness to adopt the SQM. In multivariate analyses, only awareness of the SQM initiative (B=0.34, standard error (SE) 0.08, t=4.4, p<0.0001) and leadership support (B=0.45, SE 0.11, t=4.0, p<0.0001) were significantly associated with readiness to adopt this system. CONCLUSION: While treatment providers report high levels of readiness to adopt the SQM system, findings show that the likelihood of adoption can be further increased through improved provider awareness and enhanced leadership support for this health innovation.

The prevalence and correlates of untreated serious mental illness.

OBJECTIVE: To identify the number of people in the United States with untreated serious mental illness (SMI) and the reasons for their lack of treatment. DATA SOURCE/STUDY DESIGN: The National Comorbidity Survey; cross-sectional, nationally representative household survey. DATA COLLECTION: An operationalization of the SMI definition set forth in the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act identified individuals with SMI in the 12 months prior to the interview. The presence of SMI then was related to the use of mental health services in the past 12 months. PRINCIPAL FINDINGS: Of the 6.2 percent of respondents who had SMI in the year prior to interview, fewer than 40 percent received stable treatment. Young adults and those living in nonrural areas were more likely to have unmet needs for treatment. The majority of those who received no treatment felt that they did not have an emotional problem requiring treatment. Among those who did recognize this need, 52 percent reported situational barriers, 46 percent reported financial barriers, and 45 percent reported perceived lack of effectiveness as reasons for not seeking treatment. The most commonly reported reason both for failing to seek treatment (72 percent) and for treatment dropout (58 percent) was wanting to solve the problem on their own. CONCLUSIONS: Although changes in the financing of services are important, they are unlikely by themselves to eradicate unmet need for treatment of SMI. Efforts to increase both self-recognition of need for treatment and the patient centeredness of care also are needed.

Rural and urban differences in continuity of care after state hospital discharge.

In a study to determine differences in continuity of care for state hospital patients discharged to rural and urban areas, all community mental health centers in Virginia were asked to complete a brief questionnaire about each patient discharged to the centers in fiscal year 1992. Discharges to rural centers had significantly higher levels of continuity of care on four of five dimensions of continuity. The authors conjecture that rural centers' lower staff ratios and decreased role boundaries may make them better able than urban centers to carry out the diverse tasks needed to help discharged patients resume community living.

A multistakeholder-driven model for developing an outcome management system.

Increasing demands for accountability in the delivery of public mental health services are engendering organized systems of treatment outcome monitoring. As such systems are designed and implemented, it is critical that key stakeholders be involved to the greatest extent possible in developing assessment instruments and methodologies so as to ensure relevance and acceptability of the outcome management system. A multistakeholder-based initiative for developing standardized outcome assessment for public mental health services in Virginia is described. Key components of the initiative include the process by which stakeholders were enlisted, the identification of recommended assessment instruments, and a pilot project that began the evaluation of the feasibility, utility, and cost-benefit of using the instruments. To illustrate features of this initiative, the child/adolescent mental health pilot project is described in detail. Implications for behavioral health administrators and next steps for Virginia's outcome management system are discussed, highlighting the role of key stakeholders.

A preliminary investigation of the AUDIT and DUDIT in comparison to biomarkers for alcohol and drug use among HIV-infected clinic attendees in Cape Town, South Africa.

OBJECTIVE: There is growing concern about the effect of substance use on HIV treatment outcomes. The study objectives included: (i) evaluating whether the use of validated questionnaires (AUDIT and DUDIT) provide useful and consistent information of alcohol and drug consumption when compared with the use of biomarkers of alcohol in (urine and hair) and drugs in (urine) and (ii) assessing the feasibility of using self-report measures compared with urine and hair tests. METHOD: Participants were HIV positive patients attending an HIV community health clinic in Kraaifontein, Cape Town. Hair and urine samples were collected and analysed for alcohol, in Fatty Acid Ethyl Esters (FAEE) and in Ethyl Glucuronide and (EtG), and drugs. Biological markers were compared with self-report measures of alcohol and drug consumption in terms of sensitivity, specificity. Forty-three participants completed the self-report measures, while 30 provided hair and urine samples. RESULTS: On the AUDIT, 18 (41.9%) participants screened positive for harmful and hazardous drinking and 13 (30.2%) participants on the DUDIT screened positive for having a drug-related problem. Two of 30 participants (7%) tested positive for alcohol abuse on FAEE analysis. For EtG, 6 of 24 (25%) participants tested positive for alcohol abuse. On hair drug analysis, all 30 participants tested negative for cannabis, amphetamines, opiates, cocaine, PCP and methaqualone. On the urinalysis, 1 of 30 participants tested positive for cannabis and everyone tested negative for all other drugs included in the screening. CONCLUSION: Substance use among patients attending HIV clinics appears to be a problem, especially alcohol. Self-report measures seem to be a more cost effective option for screening of alcohol and drug abuse in resource poor settings.

Predicting whether patients receive continuity of care after discharge from state hospitals: policy implications.

This article reports the results of a comprehensive study of predictors of factors influencing continuity of care for individuals discharged from state hospitals to communities. Continuity of care is defined and the predisposing, enabling and need factors are examined using a statewide database. The conceptual model is based on community support system principles, and it drives the research. The findings will influence policy, which will then affect community support system principles. Logistic regression analysis is employed as statistical analysis that lends itself to graphical form. Implications for policy and future research are presented.

The provision of services for rural youth with serious emotional and behavioral problems: Virginia's Comprehensive Services Act.

The problems of the delivery of mental health and social services to rural children and adolescents encapsulate many of the problems in the larger health care system. Consequently, many of the principles underlying the President's Health Security Plan are applicable to the reformation of this more specialized service system. The experience of the Commonwealth of Virginia in implementing the Comprehensive Services Act (CSA) highlights the scope of vision needed to transform an existing service delivery system into a coordinated system of care on a state-wide scale.

Antituberculosis drug resistance in south Texas.

The incidence of antituberculosis drug resistance in South Texas has been tabulated. Age, sex, and ethnic group were not found to significantly influence the incidence of resistance. The incidence of resistance to isoniazid (NH) was 16.4%, ethambutol, 3.9%, rifampin, 10.6%, and streptomycin, 7.8%. There was a 7.3% rate of resistance to INH and/or ethambutol or rifampin for any individual organism (i.e., to 2 of the 3 most commonly used antituberculosis drugs). We conclude that the incidence of single and multiple antituberculosis drug resistance in South Texas is higher than previously reported.

Ozone sensitivity in hybrid poplar correlates with insensitivity to both salicylic acid and jasmonic acid. The role of programmed cell death in lesion formation.

Our earlier studies demonstrated that the ozone-sensitive hybrid poplar clone NE-388 displays an attenuated level of ozone-, wound-, and phytopathogen-induced defense gene expression. To determine if this reduced gene activation involves signal transduction pathways dependent on salicylic acid (SA) and/or jasmonic acid (JA), we compared the responses of NE-388 and an ozone-tolerant clone, NE-245, to these signal molecules. JA levels increased in both clones in response to ozone, but only minimal increases in SA levels were measured for either clone. Treatment with SA and methyl jasmonate induced defense gene expression only in NE-245, indicating that NE-388 is insensitive to these signal molecules. DNA fragmentation, an indicator of programmed cell death (PCD), was detected in NE-245 treated with either ozone or an avirulent phytopathogen, but was not detected in NE-388. We conclude that these clones undergo two distinct mechanisms of ozone-induced lesion formation. In NE-388, lesions appear to be due to toxic cell death resulting from a limited ability to perceive and subsequently activate SA- and/or JA-mediated antioxidant defense responses. In NE-245, SA-dependent PCD precedes lesion formation via a process related to the PCD pathway activated by phytopathogenic bacteria. These results support the hypothesis that ozone triggers a hypersensitive response.