Participation and diffusion effects of a peer-intervention for HIV prevention among adults in rural Malawi.

This paper examines whether a peer group intervention that reduced self-reported risky behaviors for rural adults in Malawi also had impacts on non-participants in the same communities. We randomly assigned two districts to the intervention and control conditions, and conducted surveys at baseline and 18 months post-intervention using unmatched independent random samples of intervention and control communities in 2003-2006. The six-session peer group intervention was offered to same-gender groups by trained volunteers. In this analysis, we divided the post-intervention sample into three exposure groups: 243 participants and 170 non-participants from the intervention district (total n = 415) and 413 control individuals. Controlling for demographics and participation, there were significant favorable diffusion effects on five partially overlapping behavioral outcomes: partner communication, ever used condoms, unprotected sex, recent HIV test, and a community HIV prevention index. Non-participants in the intervention district had more favorable outcomes on these behaviors than survey respondents in the control district. One behavioral outcome, community HIV prevention, showed both participation and diffusion effects. Participating in the intervention had a significant effect on six psychosocial outcomes: HIV knowledge (two measures), hope, condom attitudes, and self-efficacy for community HIV prevention and for safer sex; there were no diffusion effects. This pattern of results suggests that the behavioral changes promoted in the intervention spread to others in the same community, most likely through direct contact between participants and non-participants. These findings support the idea that diffusion of HIV-related behavior changes can occur for peer group interventions in communities, adding to the body of research supporting diffusion of innovations theory as a robust approach to accelerating change. If diffusion occurs, peer group intervention may be more cost-effective than previously realized. Wider implementation of peer group interventions can help meet the global goal of reducing new HIV infections.

Peer group intervention for HIV prevention among health workers in Chile.

We tested the impacts of a professionally assisted peer-group intervention on Chilean health workers' HIV-related knowledge, attitudes, and behaviors using a quasi-experimental design with a pretest and 3-month posttest. Two Santiago suburbs were randomly assigned to the intervention or delayed intervention control condition. Five community clinics per suburb participated. Interested workers at the intervention (n = 262) and control (n = 293) clinics participated and completed both evaluations. At posttest, intervention clinic workers had higher knowledge and more positive attitudes regarding HIV, condoms, stigmatization, and self-efficacy for prevention. They reported more partner discussion about safer sex, less unprotected sex, and more involvement in HIV prevention activities in the clinic and the community, but they did not report fewer sexual partners or more standard precautions behaviors. Because of these positive impacts, the program will become a regular continuing education unit that can be used to meet health-worker licensing requirements.

Outcomes of an HIV prevention peer group intervention for rural adults in Malawi.

This study used a quasi-experimental design to evaluate a six-session peer group intervention for HIV prevention among rural adults in Malawi. Two rural districts were randomly assigned to intervention and control conditions. Independent random samples of community adults compared the districts at baseline and at 6 and 18 months postintervention. Using multiple regressions controlling for six demographic factors, intervention district adults had significantly more favorable outcomes at 6- and 18-month evaluations for condom attitudes, self-efficacy for community prevention, self-efficacy for practicing safer sex, partner communication, using condoms ever in the past 2 months, and community prevention activities. Knowledge and hope for controlling the epidemic were significantly higher in the intervention district only at the 6-month evaluation; having a recent HIV test was significantly higher only at 18 months. Levels of stigma and the number of risky sex practices did not decrease when demographic factors were controlled. Expanding peer group intervention for HIV prevention would benefit rural adults.

Peer group intervention reduces personal HIV risk for Malawian health workers.

PURPOSE: To test a peer group intervention to address personal HIV prevention needs of rural health workers in Malawi. DESIGN: Using a quasi-experimental design, we compared district health workers in two districts of Malawi that were randomly assigned to either the intervention or delayed control condition. We used independent sample surveys at baseline, 15 months, and 30 months postintervention. Intervention district workers received a peer group intervention after the baseline; control district workers received the delayed intervention after final data collection. METHODS: The 10-session intervention for primary prevention of HIV infection was based on the primary healthcare model, behavioral change theory, and contextual tailoring based on formative evaluation. Differences in HIV-related knowledge, attitudes, self-efficacy, and behaviors were analyzed using t tests and multiple regression controlling for baseline differences. FINDINGS: Health workers in the intervention district had higher general HIV knowledge, more positive attitudes about condoms, higher self-efficacy for safer sex, and more involvement in community HIV prevention at both the 15-month and 30-month postintervention survey. At 30 months, intervention district workers also reported less stigmatizing attitudes toward persons living with AIDS, more HIV tests, and lower risky sexual behaviors. CONCLUSION: The intervention should be sustained in current sites and scaled up for health workers throughout Malawi as part of a multisectoral response to HIV prevention. CLINICAL RELEVANCE: Incorporating a peer group intervention focused on personal as well as work-related HIV prevention can reduce health workers' risky behaviors in their personal lives, potentially reducing morbidity and mortality and enhancing workforce retention. Reducing stigmatizing attitudes may also improve the quality of health services.

Improving universal precautions and client teaching for rural health workers: a peer-group intervention.

Health workers can contribute to HIV prevention by minimizing HIV transmission in health facilities and increasing client teaching. We offered a peer-group intervention for Malawian rural health workers to build their universal precautions and teaching skills. A quasi-experimental design using independent sample surveys and observations compared health workers in an intervention and delayed intervention control district at baseline and at 15 and 30 months post-intervention. Controlling for demographic factors, the intervention district had more reported HIV teaching at 15 and 30 months and also had higher universal precautions knowledge and fewer needle stick injuries at 30 months. Observations at 15 and 30 months post-intervention showed higher levels of teaching in the intervention district. Observed glove wearing and hand washing were also higher at 30 months. This intervention should be made available for health workers in Malawi and provides a potential model for other high-HIV prevalence countries.

African-American adolescent girls' initiation of sexual activity: survival analysis.

PURPOSE: African-American adolescent females tend to initiate participation in sexual activity at an earlier age than Caucasian adolescent females. Early initial participation in sexual activity is associated with increased risk of HIV infection. However, limited prospective data are available on the rate at which African-American adolescent females delay their initial participation in sexual activity. The purpose is to determine low-income, inner-city, African-American adolescent females' survival or continued nonparticipation in sexual activity over a 20-month period and to determine predictors associated with survival. METHODS: A longitudinal, quasi-experimental research design with multiple data collection points was used. The convenience sample consisted of 396 African-American females with a mean age of 12.4 years (SD = 1.1 years) and their mothers. The adolescents completed questionnaires assessing perceptions of maternal monitoring, HIV transmission knowledge, self-efficacy to refuse sex, intention to refuse sex, and age. Their mothers completed questionnaires assessing perception of maternal monitoring, safer sex self-efficacy, marital status, and educational level. At baseline, the adolescents reported nonparticipation in sexual activity. Survival analysis was conducted to determine the timing and predictors of sexual activity initiation for these adolescents. FINDINGS: Of the 396 adolescents, 28.5% did not survive; they participated in sexual activity within the 20-month period. Predictors of non-survival were the adolescents' age, perception of maternal monitoring, and intention to refuse sex. CONCLUSION: Findings suggest interventions that increase maternal monitoring and adolescents' intentions to refuse sex could be beneficial in delaying sexual activity.

Impact of a peer-group intervention on occupation-related behaviors for urban hospital workers in Malawi.

Using a pre- and posttest design with no control group, the authors evaluated the impact of a peer-group intervention on work related knowledge and behavior for health workers at an urban hospital in Malawi. The authors surveyed unmatched random samples of health workers, observed workers on the job, and interviewed clients about hospital services at baseline and at 6 months after the intervention. Universal precautions knowledge, reported hand washing, and reported client teaching were significantly higher at the final evaluation. The outcome differences remained robust in multivariate analyses with controls for demographic factors of age, gender, education, food security, and job category. Observations reported consistently greater use of universal precautions, more respectful interactions, and more client teaching at final evaluation. Patient surveys reported more discussion with health workers about HIV at the final evaluation. Peer-group interventions can prepare health workers in Malawi for HIV prevention and offer a potential model for other African countries.

Impacts of a peer-group intervention on HIV-related knowledge, attitudes, and personal behaviors for urban hospital workers in Malawi.

This report describes the effects of a peer-group intervention on Malawian urban hospital workers' HIV-related personal knowledge, attitudes, and behaviors. More than 850 clinical and nonclinical hospital workers received the intervention. Evaluation used independent surveys of a sample of workers at baseline (N = 366) and postintervention (N = 561). Compared with the baseline survey, after the intervention, workers had higher knowledge of HIV transmission and prevention; more positive attitudes including more hope, less stigmatization of persons with HIV, more positive attitudes toward HIV testing and condom use, and higher self-efficacy for practicing safer sex and for community prevention; more reported recent personal HIV tests, more discussion of safer sex with partners, and more reported community HIV prevention activities. However, health workers' risky sexual behaviors did not differ at baseline and postintervention. The intervention should be strengthened to support more sexual risk reduction and be made available to all health workers in Malawi.

African American Adolescent Females: Mother-Involved HIV Risk-Reduction Intervention.

African American adolescent females continue to be at disproportionate high risk for HIV infection. A repeated measures quasi-experimental comparison group design compared an HIV risk-reduction intervention delivered by mothers with an HIV risk-reduction intervention delivered by health professionals and with a health promotion intervention delivered by mothers. The three interventions were randomly assigned to one of three geographical distinct sites. A convenience sample of 553 low-income African American adolescent girls with a baseline age of 11 to 14 years participated in the study. The results revealed that over a 6-month period, compared to girls in the health promotion intervention, the girls in the HIV risk-reduction interventions had significant higher scores on HIV transmission knowledge, condom attitudes, and self-efficacy to use condoms. The implication is mothers who receive appropriate training may be able to deliver HIV risk reduction to their daughters as well as health professionals.

Effects of health literacy on health status and health service utilization amongst the elderly.

Amid increased concerns about the adverse consequences of low health literacy, it remains unclear how health literacy affects health status and health service utilization. With a sample of 489 elderly Medicare patients in a Midwestern city in the USA, we explored the intermediate factors that may link health literacy to health status and utilization of health services such as hospitalization and emergency care. We expected to find that individuals with higher health literacy would have better health status and less frequent use of emergency room and hospital services due to (1) greater disease knowledge, (2) healthier behaviors, (3) greater use of preventive care, and (4) a higher degree of compliance with medication. Using path analysis, we found, however, that health literacy had direct effects on health outcomes and that none of these variables of interest was a significant intermediate factor through which health literacy affected use of hospital services. Our findings suggest that improving health literacy may be an effective strategy to improve health status and to reduce the use of expensive hospital and emergency room services among elderly patients.

Smoking cessation processes in low-SES women: the impact of time-varying pregnancy status, health care messages, stress, and health concerns.

UNLABELLED: We tracked smoking outcomes - quitting, stage of readiness, action, motivation, self-efficacy, and confidence - over time among 943 low-SES women smokers accrued in an earlier smoking cessation intervention trial conducted in public health clinics. We assessed outcomes at 2, 6, 12 and 18 months post-initial clinic visit. Controlling for baseline characteristics and earlier program participation, we used hierarchical linear modeling to assess how intervening life events - pregnancy and exposure to subsequent clinic smoking interventions - affected smoking outcomes directly and indirectly, through the mediators, perceived stress and health concerns. RESULTS: All longitudinal smoking outcomes were positively related to health concerns and negatively related to perceived stress. Pregnancy favorably influenced all smoking outcomes but confidence, but exposure to additional interventions affected only motivation. Health concerns and stress partially mediated the positive impact of pregnancy. CONCLUSION: Public health efforts targeted to low-SES women smokers should continue to emphasize the benefits of quitting smoking for health maintenance and incorporate more effective stress-coping mechanisms. Pregnancy increases abstinence, but preventing post-delivery relapse may require stress management and re-focusing of health concerns.

A path model of smoking cessation in women smokers of low socio-economic status.

The goals of this study were to (i) determine how factors commonly implicated in smoking cessation processes influenced smoking cessation in low socio-economic status (SES) women and (ii) elucidate the pathways through which these factors may lead to quitting smoking. Secondary analysis was conducted on data from 644 women smokers aged 18-45 years who had participated in an earlier experimental evaluation of a smoking cessation program, were still smokers at the 2-month post-intervention survey and completed an interview 6 months later. Path analysis (LISREL 8) was used to test a conceptual model in which (i) factors considered as precursors to quitting (motivation, self-efficacy, confidence, action and intention to quit) directly predicted subsequent quitting and (ii) health concerns, social pressure to quit and daily stress influenced quitting indirectly through their effects on the precursor factors and (iii) mediated the effects of background characteristics (race, education, single motherhood, pregnancy and exposure to the earlier smoking cessation intervention) on quitting. Overall, results supported this conceptual model and its applicability to low-SES women smokers and indicated significant pathways among specific factors. In particular, (i) only plans to quit, confidence and social pressure to quit directly predicted quitting; (ii) both health concerns and social pressure increased motivation to quit and (iii) the negative effect of daily stress on quitting was mediated through decreased self-efficacy.

Mothers' effectiveness as HIV risk reduction educators for adolescent daughters.

Low-income African American inner city adolescent females continue to be at disproportionately high risk for contracting HIV. Though it has been speculated that mothers' involvement in HIV risk reduction may be helpful in the fight against HIV, very few interventions involve mothers. The Mother/Daughter HIV Risk Reduction intervention (MDRR), an innovative community-based intervention, trains mothers to be their daughters' primary HIV educators. A split-plot repeated measures design was used to test the effectiveness of the MDRR in decreasing daughters' sexual activity over a 2-month period. The mediating variables were daughters' HIV transmission knowledge, self-efficacy and intention to refuse sex. The sample consisted of 262 daughters with a mean age of 12.4 years. The results revealed that mothers were effective in increasing the mediating variables and in reducing their daughters' level of sexual activity. Active involvement of mothers is cost-effective and should be integrated into HIV intervention programs.

The impact of adult roles on drinking among women in the United States.

This paper examines the impact of three adult roles-spouse, parent, and worker-on psychological distress and drinking among a national sample of 10,193 women in the United States, using the 1992 National Household Survey on Drug Abuse (NHSDA). We found that the spouse and worker roles are negatively associated with the level of psychological distress, and the parent role is positively correlated with it. Controlling for level of psychological distress, those workers generally are more likely to be drinkers, but, among drinkers, they do not consume alcoholic beverages more than non-workers. The family roles do not affect a woman's likelihood of being a drinker. However, among the drinkers, being a spouse or a parent is negatively related with level of alcohol consumption. Separating three aspects of drinking behavior-whether a woman drinks at all and, if she drinks, her levels of alcohol consumption and problem drinking-our findings suggest that drinking is not a unidimensional construct. A woman's roles influence various dimensions of her drinking differently.

African-American adolescent females' predictors of having sex.

African-American adolescent females are at high risk for HIV infection, acquired primarily as a result of heterosexual intercourse. Multiple regression analyses was used to describe the correlates of the outcome variable, ever having had sex, for low-income African-American adolescent females in a cross-sectional study of 322 (N = 322) mother/daughter pairs. The results revealed that while the daughters' age was positively associated with the outcome variable, the daughters' perceptions of strictness of curfew and maternal monitoring, and the daughters'self-efficacy to refuse sex and their intention to refuse sex were negatively associated with the outcome variable. Mothers tended to report significantly more maternal monitoring and stricter curfews than what their daughters perceived them to be. The daughters'intention to refuse sex mediated the effects of age and self-efficacy to refuse sex on the outcome variable. These results suggest that health-care providers should promote clearer communication between mothers and daughters in order to reduce divergent perceptions and to help mothers facilitate their daughters' self-efficacy and their intention to refuse sex.

Risk factors for tuberculosis among inmates: a retrospective analysis.

This paper examined risk factors associated with TB among inmates, over a 7-year period, and the association of ethnicity and gender with these risk factors. We performed retrospective analysis of data on former inmates from a county jail. TB status at admission was explained with demographics, behavioral risk factors, and incarceration factors. We examined ethnicity and gender defenses on the risk factors. A total of 441 TB cases and 478 non-TB cases were included. Inmates were more likely to have TB if they were whites, unmarried, homeless, alcohol abusers, and HIV positive. Inmates with TB had even lower socioeconomic status and more behavioral risk factors than other inmates. They had fewer incarcerations and less serious crimes, but longer jail stays. TB risk factors differed by ethnicity and gender. TB control in jails requires intervention in the communities where inmates live. Correctional health is a critical part of public health. Public health nurses are responsible for better understanding and improving health care for this high-risk and difficult-to-reach population.

Long-term effects (up to 18 months) of a smoking cessation program among women smokers in public health clinics.

BACKGROUND: We conducted longitudinal analysis of long-term outcomes of a motivational smoking cessation program. The program consisted of clinic-based minimal interventions delivered to women smokers in public health clinics by clinic personnel, a reminder letter, and an optional brief telephone counseling. METHODS: Subjects seen in six intervention (N=541) and six control clinics (N=527) were interviewed by telephone 2, 6, 12, and 18 months later. At each measurement point, unadjusted percent abstinence and mean action, motivation, and readiness scores by study group were compared with standard bivariate comparisons tests. Hierarchical linear modeling that adjusted for clustering of subjects within clinics and clustering of results over 18 months (four waves) within individuals was used to compare outcomes by study group. RESULTS: Number of actions toward quitting, motivation, and stage of readiness to quit remained better in the intervention than in the control group up to 18 months. The program effect on abstinence was still significant at 12 months, but not at 18 months. CONCLUSIONS: Exposure to one-time, brief interventions in public health clinics appears sufficient to enhance abstinence up to 12 months, and action toward quitting and motivation and readiness to quit up to 18 months.

Maternal and infant outcomes at one year for a nurse-health advocate home visiting program serving African Americans and Mexican Americans.

This article describes the outcomes at 1 year for a randomized clinical trial of Resources, Education and Care in the Home-Futures: a program to reduce infant mortality through home visits by a team of trained community residents led by a nurse. Low-income, inner-city pregnant women who self-identified as African American or Mexican American were recruited in two university prenatal clinics in Chicago. Because African Americans and Mexican Americans differed greatly at intake, we compared their outcomes at 12 months and then examined the effects of the intervention separately for these two groups. Participants were randomly assigned to the intervention or control group and were interviewed during the last trimester of pregnancy and at 2, 6, and 12 months after birth. The effects of the program varied by race/ethnicity. For African Americans, the program was associated with better maternal documentation of infant immunizations, more developmentally appropriate parenting expectations, and higher 12-month infant mental development scores. For Mexican Americans, the program had positive effects on maternal daily living skills and on the play materials subscale of the Home Observation for the Measurement of the Environment assessment. This study, along with previous research, suggests that home visits by a nurse-health advocate team can improve maternal and infant outcomes even for inner-city, low-income, minority families. Effective programs must be culturally sensitive, intensive, and adequately staffed and financed.