Nursing case management, peer coaching, and hepatitis a and B vaccine completion among homeless men recently released on parole: randomized clinical trial.

BACKGROUND: Although hepatitis A virus (HAV) and hepatitis B virus (HBV) infections are vaccine-preventable diseases, few homeless parolees coming out of prisons and jails have received the hepatitis A and B vaccination series. OBJECTIVES: The study focused on completion of the HAV and HBV vaccine series among homeless men on parole. The efficacy of three levels of peer coaching (PC) and nurse-delivered interventions was compared at 12-month follow-up: (a) intensive peer coaching and nurse case management (PC-NCM); (b) intensive PC intervention condition, with minimal nurse involvement; and (c) usual care (UC) intervention condition, which included minimal PC and nurse involvement. Furthermore, we assessed predictors of vaccine completion among this targeted sample. METHODS: A randomized control trial was conducted with 600 recently paroled men to assess the impact of the three intervention conditions (PC-NCM vs. PC vs. UC) on reducing drug use and recidivism; of these, 345 seronegative, vaccine-eligible subjects were included in this analysis of completion of the Twinrix HAV/HBV vaccine. Logistic regression was added to assess predictors of completion of the HAV/HBV vaccine series and chi-square analysis to compare completion rates across the three levels of intervention. RESULTS: Vaccine completion rate for the intervention conditions were 75.4% (PC-NCM), 71.8% (PC), and 71.9% (UC; p = .78). Predictors of vaccine noncompletion included being Asian and Pacific Islander, experiencing high levels of hostility, positive social support, reporting a history of injection drug use, being released early from California prisons, and being admitted for psychiatric illness. Predictors of vaccine series completion included reporting having six or more friends, recent cocaine use, and staying in drug treatment for at least 90 days. DISCUSSION: Findings allow greater understanding of factors affecting vaccination completion in order to design more effective programs among the high-risk population of men recently released from prison and on parole.

Correlates of Heroin and Methamphetamine Use among Homeless Male Ex-Jail and Prison Offenders.

Homeless men exiting California State jails and prisons are a heterogeneous community with varied childhood, incarceration and drug use histories. This cross-sectional study assessed whether homeless men who were discharged from either jail or prison into a residential substance abuse treatment program, differed in terms of methamphetamine and heroin use. This study utilized baseline data collected on 540 recently paroled men randomized to one of three programs that assessed the impact of a peer coaching intervention on subsequent drug use and re-incarceration. We found that younger ex-offenders exiting prisons and jails were more likely to have used methamphetamine alone, whereas African American ex-offenders were less likely to have used methamphetamine alone when compared to other ethnic groups. Further, ex-offenders exiting jails and self-reporting use of heroin only at baseline were significantly more likely than their counterparts to have been removed from home before age 18. For men exiting jails, there was an association between lower self-esteem and having used methamphetamine but not heroin. However, having used both heroin and methamphetamine was associated with both violent crime and cognitive problems in both jail and prison samples. Our findings showcase the need to understand unique correlates of both heroin and methamphetamine as they relate to jail and prison populations.

Predictors of High Level of Hostility among Homeless Men on Parole.

High levels of hostility present a formidable challenge among homeless ex-offenders. This cross-sectional study assessed correlates of high levels of hostility using baseline data collected on recently-released male parolees (N=472; age 18-60) participating in a randomized trial focused on prevention of illicit drug use and recidivism. Predictors of high levels of hostility included greater depressive symptomatology, lower self-esteem, having a mother who was treated for alcohol/drugs, belonging to a gang, more tangible support, having used methamphetamine and having a history of cognitive difficulties. These findings highlight the need to understand predictors of hostility among recently released homeless men and how these predictors may relate to recidivism. Research implications are discussed as these findings will shape future nurse-led harm reduction and community-based interventions.

Correlates of stigma among rural Indian women living with HIV/AIDS.

AIDS-related stigma has received increasing attention in the literature; however, little is known about the devastating impact it has on rural women living with AIDS (WLA) in India. This cross-sectional study (N = 68), analyzed from complete baseline data, identified a number of correlates of stigma among rural WLA in South India. Structured instruments were used to capture sociodemographic history, stigma, knowledge of HIV, depressive symptoms along with the recording of CD4 data. A higher level of felt stigma and more AIDS symptoms were related to avoidant coping, while fewer adherence strategies and lower support for antiretroviral therapy (ART) adherence were also associated with avoidant coping. These findings promote the need for support and resources for rural Indian WLA.

Impact of nursing intervention on improving HIV, hepatitis knowledge and mental health among homeless young adults.

In a prospective two-group pilot study of a convenient sample of 156 young adults, we assessed improvement in HIV cognitive and transmission knowledge, hepatitis knowledge, and mental health at six-month follow-up. Multiple linear regression analysis revealed higher six-month scores in total HIV/AIDS knowledge, HIV/AIDS cognitive knowledge, HIV transmission knowledge and HBV and HCV knowledge at 6 months in the Hepatitis Health Promotion (HHP) group compared to the Art Messaging (AM) group. Moreover, homeless young participants who reported having significant others in their lives, and excellent or very good health did better than their counterparts. Youth who were attempting to get their lives together had higher scores for all types of knowledge except HBV. Hallucinogen users had significantly worse scores on all knowledge measures than non-users. Lastly, the HHP group revealed an improvement in psychological well-being compared to the AM group.

Belief in divine control, coping, and race/ethnicity among older women with breast cancer.

BACKGROUND: Belief in divine control is often assumed to be fatalistic. However, the assumption has rarely been investigated in racial/ethnic minorities. OBJECTIVES: This study aims to examine the association between belief in divine control and coping and how the association was moderated by ethnicity/acculturation in a multi-ethnic sample of breast cancer patients. METHODS: Latina, African American, and non-Hispanic White older women with newly diagnosed breast cancer (N=257) from a population-based survey completed the scale of Belief in Divine Control and the Brief COPE. RESULTS: Belief in divine control was positively related to approach coping (i.e., positive reframing, active coping, and planning) in all ethnic groups. Belief in divine control was positively related to acceptance and negatively related to avoidance coping (i.e., denial and behavioral disengagement) among low-acculturated Latinas. CONCLUSIONS: Negative presumptions about fatalistic implications of belief in divine control should be critically reappraised, especially when such skepticism is applied to racial/ethnic minority patients.

Characteristics of homeless youth who use cocaine and methamphetamine.

This cross-sectional hepatitis health promotion study (N = 156) was designed to identify correlates of cocaine and methamphetamine use among young, homeless persons living in Los Angeles County. Structured questionnaires were administered at baseline to assess sociodemographic characteristics, drug history, and social support. Unadjusted analysis showed that older age, having a history of incarceration, injection drug use (IDU), 10 or more sexual partners, and sex for money were associated with both cocaine and methamphetamine use. Logistic regression results showed that injection drug users had over seven times greater odds of using each stimulant compared with nonusers of injection drugs; those reporting at least 10 sexual partners and alcohol use in the past 6 months were more likely to use cocaine than their respective counterparts. African Americans were also less likely than Whites to report cocaine use. Understanding of these relationships can guide interventions targeting the multiple challenges faced by this population.

Impact of nursing intervention on decreasing substances among homeless youth.

BACKGROUND: Alcohol use, and in particular, binge drinking, and methamphetamine use is pervasive among homeless youth and remains a social pressure among this vulnerable population. However, there is no compelling evidence that specific interventions for reducing drug and alcohol use are effective for homeless youth. OBJECTIVES: This community-based participatory action pilot study assessed the impact of an intervention study focused on decreasing use of drugs and alcohol among a sample of homeless young adults (N= 154) visiting a drop-in site in Santa Monica, California. The two programs consisted of an HIV/AIDS and Hepatitis Health Promotion (HHP) program led by nurses and an Art Messaging (AM) program led by artists. Six-month follow-up data were obtained from 100 of these individuals. RESULTS: Findings revealed significant reductions in alcohol and marijuana use and binge drinking in both the HHP and AM programs. However, homeless youth in the HHP program reported additional reductions in methamphetamine, cocaine, and hallucinogen use at 6-month follow-up. CONCLUSIONS: Reductions in drugs and alcohol are important as these substances are linked to HIV/AIDS, hepatitis, and other health risks in homeless youth. SCIENTIFIC SIGNIFICANCE: The successful outcomes of the study intervention validate the utility of nurse-led and artistic health promotion strategies to decrease drug and alcohol use and other risky behaviors in homeless youth populations.

Correlates of depressive symptoms among alcohol-using methadone maintained adults.

BACKGROUND: Alcohol-using clients are considered at great risk for hepatitis and ongoing liver damage. This study explores the correlates of depression among a sample of methadone maintained treatment (MMT) adults in the Los Angeles area, and is part of a larger study on hepatitis health promotion among MMT clients who use alcohol. OBJECTIVES: We sought to determine correlates of depressive symptoms among moderate and heavy alcohol-using adults enrolled in methadone maintenance. METHODS: A cross-sectional correlation study was conducted of baseline data from a randomized control trial of adults (N= 189) receiving MMT in Los Angeles. Depressive symptoms were measured with the 10-item short-form CES-D. RESULTS: Multiple regression analysis revealed that pain and social support were key correlates of depressive symptoms. More pain was associated with higher levels of depressive symptoms (p= .001), while more social support was related to lower depressive symptom severity (p= .001). Having been in sufficiently poor health that a blood transfusion, clotting factors, or an organ transplant was necessary was associated with greater depressive symptomatology, as was having injected drugs in the past month (p= .024). CONCLUSIONS: The findings from this investigation can aid clinicians in selecting clients to monitor for early signs of depression and encourage early treatment for opioid users with comorbidities. SCIENTIFIC SIGNIFICANCE: The use of an interdisciplinary team to care for MMT clients, routinely screen for depressive symptoms, and emphasize adequate pain control is indicated.

Impact of a rural village women (Asha) intervention on adherence to antiretroviral therapy in southern India.

BACKGROUND: Despite the increased prevalence of HIV in the rural female population of India, adherence to antiretroviral therapy continues to be low because of several barriers that discourage rural women. OBJECTIVES: This study aims to assess the effectiveness of an intervention (Asha-Life) delivered by Accredited Social Health Activists (Asha) to improve antiretroviral therapy adherence of rural women living with AIDS in India compared with that of a usual care group. METHODS: Sixty-eight rural women living with AIDS, aged 18-45 years, participated in a prospective, randomized pilot clinical trial and were assessed for several factors affecting adherence, such as sociodemographic characteristics, health history, CD4 cell count, enacted stigma, depressive symptomology, help getting antiretroviral therapy, and perceived therapy benefits. RESULTS: Findings at 6 months revealed that, although both groups improved their adherence to antiretroviral therapy, there was greater improvement in the Asha-Life group (p < .001), who reported a greater reduction in barriers to antiretroviral therapy than those in the usual care group. DISCUSSION: Antiretroviral therapy adherence showed significant increase in the Asha-Life cohort in which basic education on HIV/AIDS, counseling on antiretroviral therapy, support from Ashas, financial assistance, and better nutrition, was provided. The Asha-Life intervention may have great potential in improving antiretroviral therapy adherence and decreasing barriers among rural women living with AIDS in India.

Correlates of serious violent crime for recently released parolees with a history of homelessness.

This study used baseline data on recently released paroled men who are homeless (N=157), residing in a residential drug treatment program, and enrolled in a longitudinal study to examine personal, developmental, and social correlates of parolees who are homeless and who have committed serious violent offenses. Having experienced childhood sexual abuse, poor parental relationships, and early-onset incarceration (prior to 21 years of age) were important correlates of serious violent crimes. These findings highlight the need for interventions that address offenders' prior adult and childhood victimization and suggest that policies for reentering violent offenders should encompass an understanding of the broader family contexts in which these patterns of maltreatment often occur.

Impact of prison status on HIV-related risk behaviors.

Baseline data were collected to evaluate the effectiveness of interventions on completion of the hepatitis A and B vaccine series among 664 sheltered and street-based homeless adults who were: (a) homeless; (b) recently (<1 year) discharged from prison; (c) discharged 1 year or more; and (d) never incarcerated. Group differences at baseline were assessed for socio-demographic characteristics, drug and alcohol use, sexual activity, mental health and public assistance. More than one-third of homeless persons (38%) reported prison time and 16% of the sample had been recently discharged from prison. Almost half of persons who were discharged from prison at least 1 year ago reported daily use of drugs and alcohol over the past 6 months compared to about 1 in 5 among those who were recently released from prison. As risk for HCV and HIV co-infection continues among homeless ex-offenders, HIV/HCV prevention efforts are needed for this population.

Correlates of depression among rural women living with AIDS in Southern India.

Although depression may be commonly experienced by persons living with AIDS, it may be challenging for health care providers to identify persons who are suffering from depression symptoms, particularly if they are living in the more isolated rural areas of India. The purpose of this study is to assess correlates of depression among women living with AIDS in rural Andhra Pradesh, India. A total of 68 rural women living with AIDS (WLA) completed baseline data and were assessed by means of structured instruments. Regression modeling revealed that disclosure avoidance and making at least six health care visits in the last six months were all associated with depression. Further, living with a spouse was associated with lower depressive symptom scores. Stigma was not found to be associated with depression. Understanding correlates of depression can lead the way toward designing culturally-tailored interventions that can mitigate disclosure avoidance and improve the health of women. A more comprehensive health focus may be needed to empower the women to seek quality care for both physical health, as well as mental health, symptomatology.

Correlates of depressive symptoms among homeless men on parole.

This study describes correlates of high levels of depressive symptoms among recently paroled men in Los Angeles who reside in a community substance abuse treatment program and report homelessness. Cross-sectional data were obtained from male residents who were released on parole within the last 30 days (N =157) to assess parental relationship, self-esteem, social support, coping behaviors, drug and alcohol use behaviors, depressive symptoms, and sociodemographic information. Results indicated that 40% of the participants were classified as experiencing high levels of depressive symptoms (CES-D ≥ 10). Results of a logistic regression analysis showed that the following were predictors of depressive symptoms (p <.05): physical abuse in childhood, non-residential alcohol treatment, violent behaviors, low self-esteem, and disengagement coping. Being Mexican-American, Mexican, American Indian, or Asian, and not displaying cognitive problems was inversely related to depressive symptoms in the final model (B =-2.39, p <.05). Findings support proper use of both prison and community assessment services to at-risk individuals eligible for parole to increase self-esteem and coping.

Treatment-related symptoms among underserved women with breast cancer: the impact of physician-patient communication.

Low-income, minority women are more likely to be undertreated for breast cancer (BC) treatment-related symptoms than whites. This study assessed the impact of patient-physician communication on symptom resolution. A cross-sectional, California statewide survey was conducted among 921 low-income women with BC. Ethnic/racial differences in BC treatment-related symptoms (pain, nausea/vomiting, depression) reporting and physician' awareness of these symptoms were assessed by patient report. Multivariate logistic regression models were used to investigate the impact of patient-physician communication on symptom resolution. Depression was the most common symptom reported by patients (66%), yet physicians were the least aware of it (26.3%), especially among less-acculturated Latinas (18.9%) and Asian/Pacific Islanders (14%; P < 0.001). Greater patient-perceived self-efficacy in communication with physicians and greater physician awareness of the symptom positively predicted pain resolution, controlling for sociodemographic variables, comorbidity, and treatment received (AOR = 1.05, P < 0.0001; AOR = 6.12, P < 0.001). Physician awareness was a significant determinant of depression resolution (AOR = 13.46, P < 0.001). Yet patient-perceived self-efficacy played a much more important role than physicians' awareness in nausea resolution (AOR = 1.04, P = 0.0002). Less-acculturated Latinas tended to achieve less symptom resolution than whites, while this negative impact disappeared or was moderated after patient-physician communication was considered. This study suggests that physicians under-recognized depression, especially among Latinas. The resolution of BC treatment-related symptoms can be addressed by appropriate educational interventions targeted at patient-physician communication. Effective patient-physician communication can moderate disparities in symptom resolution among Latinas, regardless of language acculturation.

Health and health care disparities among homeless women.

While disparities in health and health care between vulnerable (e.g., minorities, low-income) and majority populations are well documented, less is known about disparities within these special populations that are large and diverse. Such knowledge is essential to determine the neediest within these generally needy populations, and to plan interventions to reduce their health and health care disparities. With data from 1,331 women residing in Los Angeles County California, in one of the largest, most comprehensive studies of the health of homeless women to date, this study examined the health and health care disparities among homeless African American, Latina, and white women. This study further explored if race/ethnicity and other factors that predispose homeless women to poor health, or enable them to obtain better health care, were associated with their unmet need for medical care. The study found that white, non-Latina women were more likely to report unmet need than African Americans and Latinas, and women suffering from drug abuse, violence, or depression were most in need of care. These findings should be considered in targeting and addressing the special needs of homeless women of different racial/ethnic groups.

Effects of a nurse-managed program on hepatitis A and B vaccine completion among homeless adults.

BACKGROUND: Hepatitis B virus (HBV) infection constitutes a major health problem for homeless persons. Ability to complete an HBV vaccination series is complicated by the need to prioritize competing needs, such as addiction issues, safe places to sleep, and food, over health concerns. OBJECTIVES: The objectives of this study were to evaluate the effectiveness of a nurse-case-managed intervention compared with that of two standard programs on completion of the combined hepatitis A virus (HAV) and HBV vaccine series among homeless adults and to assess sociodemographic factors and risk behaviors related to the vaccine completion. METHODS: A randomized, three-group, prospective, quasi-experimental design was conducted with 865 homeless adults residing in homeless shelters, drug rehabilitation sites, and outdoor areas in the Skid Row area of Los Angeles. The programs included (a) nurse-case-managed sessions plus targeted hepatitis education, incentives, and tracking (NCMIT); (b) standard targeted hepatitis education plus incentives and tracking (SIT); and (c) standard targeted hepatitis education and incentives only (SI). RESULTS: Sixty-eight percent of the NCMIT participants completed the three-series vaccine at 6 months, compared with 61% of SIT participants and 54% of SI participants. NCMIT participants had almost 2 times greater odds of completing vaccination than those of participants in the SI program. Completers were more likely to be older, to be female, to report fair or poor health, and not to have participated in a self-help drug treatment program. Newly homeless White adults were significantly less likely than were African Americans to complete the vaccine series. DISCUSSION: The use of vaccination programs incorporating nurse case management and tracking is critical in supporting adherence to completion of a 6-month HAV/HBV vaccine. The finding that White homeless persons were the least likely to complete the vaccine series suggests that programs tailored to address their unique cultural issues are needed.

Correlates of heavy smoking among alcohol-using methadone maintenance clients.

This cross-sectional study examines predictors of heavy smoking among 256 male and female methadone maintenance therapy (MMT) clients from five MMT clinics in the Los Angeles area. The authors find that women report lower rates of heavy smoking than men (47% vs. 54%, respectively), in concordance with current literature pointing to gender differences in smoking behaviors. In particular, men who report heavy drinking, fair or poor health, and recent heroin use are more likely to report heavy smoking compared with men not reporting these factors. Women who report recent heroin use, a lifetime history of sex trade, and who have been ill enough to require a blood transfusion also have greater odds of reporting heavy cigarette smoking. Findings from this study may aid not only in designing gender-based smoking cessation programs for MMT clients but also in addressing the gender-based issues related to smoking in such a population.

Correlates of hospitalization for alcohol-using methadone-maintained persons with physical health problems.

This cross-sectional study (n = 190) examined correlates of hospitalization for physical health problems among methadone maintenance therapy (MMT) clients with a history of alcohol abuse. The study was derived from baseline data collected for a longitudinal trial assessing the effect of motivational interviewing among alcohol-abusing adults undergoing MMT. The sample included clients who were 18-55 years of age, abusing alcohol, and receiving MMT from five large methadone maintenance clinics in the Los Angeles area. A structured questionnaire was used to collect the data. Correlates of hospitalization in logistic regression analysis included lack of social support, recent victimization, age of first alcohol use, chronic severe pain in the previous 6 months, not having children, and ethnicity. Identification of hospitalization risk factors among alcohol-abusing MMT clients is a first step to developing risk-reducing interventions designed to lower hospitalization rates in this population.

Racial/ethnic differences in breast cancer outcomes among older patients: effects of physician communication and patient empowerment.

OBJECTIVES: To examine racial/ethnic disparities in older women's health-related quality of life (QoL) and type of breast cancer treatment as mediated by physician-level and individual-level variables. METHODS: A cross-sectional survey of a population-based, consecutive sample identified through the Los Angeles Cancer Surveillance Program of Latina (n = 99), African American (n = 66), and White (n = 92) women aged 55 years or older (N = 257) between 3 and 9 months after primary breast cancer diagnosis and at least 1 month posttreatment. An exploratory, empirically developed latent variable model tested the relationships among demographic and physician-related variables, patient attitudes, and health-related outcomes. Health-related outcomes included QoL measures and receipt of breast conserving surgery (BCS). RESULTS: Latinas reported less BCS and poorer QoL compared with Whites. Physician communication that can empower patients, in terms of patient efficacy in patient?physician interactions and breast cancer knowledge, mitigated racial/ethnic disparities in receipt of BCS. Physician emotional support was not related to patient cognitive empowerment and treatment outcomes. Medical mistrust in minority women was related to less self-efficacy and less positive coping, as well as, both directly and indirectly, to reduced QoL. Latinas reported poorer QoL in the tested model. CONCLUSION: Physician communication style, specifically information giving and participatory decision making, may empower older women with breast cancer and help mitigate racial/ethnic disparities in surgical treatment received.