Housing status and health care service utilization among low-income persons with HIV/AIDS.

OBJECTIVE: To examine the impact of housing status on health service utilization patterns in low-income HIV-infected adults. DESIGN: A survey of 1,445 HIV-infected Medicaid recipients in New York State between April 1996 and March 1997. MAIN RESULTS: Six percent of study participants were homeless, 24.5% were "doubled-up," and 69.5% were stably housed. Compared with the stably housed, doubled-up and homeless participants were less likely to be seeing a physician regularly (P = .0001), and if seeing a physician, they were likely to have been doing so for a significantly shorter time (P = .02). The homeless were also less likely than either stably housed or doubled-up individuals to see the same physician or group of physicians at each ambulatory visit (P = .007). In addition, a higher proportion of the homeless had made one or more hospital visits over the prior 3 months than the nonhomeless. After multivariate adjustment, doubled-up participants were found to make more emergency room visits, the homeless were less likely to be taking prophylaxis for Pneumocystis carinii pneumonia, and both the doubled-up and the homeless were shown to use slightly more outpatient care than the stably housed. CONCLUSION: Our study documents differences in health care utilization patterns across stably housed, doubled-up, and homeless HIV-infected persons after controlling for health insurance coverage. These differences, especially those pertaining to outpatient services, suggest that the unstably housed may be receiving less adequate health care than the stably housed, and hence may be more likely to experience adverse clinical outcomes.

Methods for identifying and assessing groups in health behavioral research.

Methods to study groups developed in other fields have much to contribute to the study of health behavior, including alcohol and substance use. This paper surveys group methods in order to demonstrate how attention to group levels of analysis can provide new insights about the context and causes of health behavior. The first major section of this paper focuses on the influences on health behavior associated with "naturally occurring groups" such as peer networks, families, workplaces, neighborhoods, churches, treatment groups and residential settings. Different aspects of group influence are discussed in terms of seven different features of social groups: history, structure, function, resources, process, norms and climate. The second major part of this paper is concerned with methods to identify meaningful subgroups in heterogeneous samples. Following an overview of taxonomic methods to identify and assign cases to groups, we highlight the potential for these methods to help address a number of fundamental theoretical problems in health behavioral research, including: describing cultural diversity, distinguishing response sets in survey research, controlling error in outcomes scores related to baseline differences, tracking trajectories of change, and revealing interactions among determinants of health behavior. The third and final section of the paper highlights specific applications of taxonomic and group-influence methodologies in intervention research, including design and analysis of randomized trials, studies of existing treatment settings and group-level variables involved in translational research.

A comparison of two approaches for assessing patient importance weights to conduct an Extended Q-TWiST analysis.

OBJECTIVE: Patient-centered methods for evaluating treatments require validated preference-elicitation techniques. We describe the validation of two preference-elicitation approaches for use in an Extended Q-TWiST treatment evaluation. The first method was an "idiographic" approach, which attempts to capture intra-individual differences in the degree to which each domain distracted from and interfered with life activities. The second method, a Likert-scaled approach, asks patients to evaluate the importance of each quality-of-life (QOL) domain. METHODS: Patient-reported QOL and preferences were assessed in participants with gastroesophageal reflux disease at baseline (n = 172), one week (n = 25), and 4 weeks after baseline (n = 100). RESULTS: Both approaches demonstrated high internal consistency and the ability to discriminate known groups based on reported pain and number of days with symptoms. The idiographic approach exhibited responsiveness, although it was more highly correlated with QOL than the Likert-scaled approach. The Likert-scaled approach had good face validity but demonstrated low reliability compared to the idiographic approach. CONCLUSIONS: Both preference-elicitation methods exhibited promise as well as limitations. Future research should focus on increasing the reliability of the Likert-scaled approach, reducing the overlap between the idiographic approach and QOL, and examining the relationship between reliability and responsiveness for a range of illness trajectories.

The relationship between health and human services and the personal goal-directed activities of persons living with AIDS.

This study evaluates the relationship between the social climate from different services and the personal goal-directed activities of 224 individuals with AIDS. The study's results supported the main hypothesis that "recipient" and "participatory" service involvement uniquely influence personal goal-directed activities, even after considering individuals with AIDS' physical symptoms, psychological distress, income, and recruitment site. Income and involvement with participatory services were both positively related to the amount of personal goal-directed activity. Longitudinal analyses suggest that personal initiative contributes to the subsequent amount of personal goal-directed activities a person pursues. These results suggest further examination of factors contributing to the selection of different service types and of the processes underlying the relationship between participatory services and positive outcomes for clients with AIDS.

End-of-life decision-making in the hospital: current practice and future prospects.

Chart review of patients who died in the hospital was used to describe the pattern of end-of-life decision-making and care for hospitalized dying patients and to propose a structured process of assessing the suitability of patients for palliative care. The setting was a large urban academic medical center, and the sample comprised 200 of 205 consecutive adult deaths during the first 4 months of 1996. The main outcome measures were identification of the patient as dying, do-not-resuscitate (DNR) orders, and comfort care plans. Charts of 72% of the patients had evidence that they were considered dying. DNR orders were in place for 77% of all the patients, and 46% had comfort care plans. Presence of a health care proxy was significantly associated with DNR orders and comfort care plans (P < 0.001). On average, comfort care plans were put in place 15 days after admission, as compared with an overall mean length of stay of 17 days. Substantial proportions of patients with comfort care plans continued to receive antibiotics (41%) and blood draws (30%). Only 13% of the patients on mechanical ventilation and 19% of those on artificial nutrition and hydration underwent withdrawal of these interventions prior to death. These findings suggest opportunities and challenges for improving practice patterns for hospitalized dying patients. We recommend several measurable objectives for evaluating end-of-life decision-making and care and propose the development of a goals of care assessment tool to guide appropriate transitions from life-sustaining treatment to comfort care and plan palliative services.

Zidovudine adherence in persons with AIDS. The relation of patient beliefs about medication to self-termination of therapy.

OBJECTIVE: To examine the relation of patient beliefs about medication usage and adherence to zidovudine (ZDV) therapy in persons with AIDS. DESIGN: Face-to-face interviews were used to determine attitudes of persons with AIDS toward ZDV and other prescribed medications, history of ZDV usage, and sociodemographics. SETTING: A public hospital infectious disease clinic, an AIDS day care program, and an inpatient unit in a voluntary hospital where care was provided cooperatively by staff and an informal-care partner. PATIENTS/PARTICIPANTS: One hundred forty-one people with the acquired immunodeficiency syndrome agreed to be reinterviewed as part of a longitudinal, New York City-based study examining outcomes related to quality of life. Initial recruitment procedures were to approach all active AIDS patients at each of the three sites between January and July of 1992: reinterviews, which were conducted an average of 6 months later, occurred from mid-1992 through May of 1993. MEASUREMENTS AND MAIN RESULTS: The Zidovudine Drug Attitude Inventory was used to assess subjective feelings and attitudes concerning ZDV and prescribed medications in general. Respondents were grouped into five categories on the basis of their ZDV usage history: (1) "short-term" users (i.e., those who had been taking ZDV for 25 months or less); (2) "long-term" users (i.e., those who had been taking ZDV for more than 25 months); (3) self-terminated users; (4) doctor-terminated users; and (5) never users. Long-term users were likely to view ZDV as an illness prophylactic. In contrast, self-terminated users and never users were most likely to believe that ZDV caused adverse side effects and that medicine need not be taken as prescribed. CONCLUSIONS: Patients' beliefs about ZDV were significantly associated with adherence-related behavior. In particular, those who had self-terminated ZDV treatment believed that taking the drug was harmful, were skeptical of its ability to prevent illness, and felt that physician's directives about medication usage in general could be disregarded. These findings highlight the importance of educating patients about ZDV and of establishing regular patient-clinician exchanges concerning patient's experience with and beliefs concerning ZDV.

Social support and barriers to family involvement in caregiving for persons with AIDS: implications for patient education.

If efforts to promote family involvement in patient education and other caregiving activities for people with AIDS (PWAs) are to be successful, clinicians need information concerning PWAs' family network and the barriers PWAs face in obtaining support. Using data from interviews with 224 PWAs in New York City, we assessed the size and composition of their family network and the self-identified barriers to support. Overall, respondents mentioned having an average of less than two sources of close support. Women relied on children for support more than men did. Male injection drug users and men reporting sex with men relied on friends and traditional family almost equally, while men at risk for HIV via heterosexual contact relied more on traditional family sources. Barriers to support included interpersonal costs, lack of access, lack of acceptance, lack of intimacy, negative interactions and fear of disclosure. Health professionals need to conduct comprehensive network assessments with PWAs in order to determine the full scope of support resources available to each patient. Educational initiatives that provide information about family conflict resolution and the course and transmission of HIV may assist in alleviating these barriers. Clinicians can facilitate family involvement in patient education by addressing the informational needs that are salient to both PWAs' and their family caregivers.

Unmet needs for help among persons with AIDS.

Current trends in AIDS care in the United States, including dehospitalization and improved outpatient treatment, may place many persons with AIDS (PWAs) at increased risk for having unmet need for help with daily living demands. Using interviews with 224 PWAs, we examined the prevalence and correlates of unmet need for assistance across six functional domains: personal care, instrumental activities of daily living (e.g. home chores, using transportation), social functioning, role performance, taking care of one's health and negotiating systems. Overall, 74.1% of respondents reported having either a partially or completely unmet need for help in one or more areas of functioning. Unmet need for help was highest for instrumental activities of daily living (46.4%). Unmet need was associated with illness severity (i.e. more symptoms and hospitalizations), minority status and support network characteristics (proximity, size and type of supporters). Implications of unmet needs data for improving the clinical care of PWAs are discussed.

Personal goals of older adults: issues in assessment and prediction.

This study identifies dimensions of individual difference in the content of older adults' personal goals and examines demographic, loss-related, and contextual influences on these goals. Results are based on the responses of 179 elders to a 112-item inventory designed to tap achievement, maintenance, disengagement, and coping goals in 16 life domains. Factor analyses yielded 10 dimensions that describe themes of global motivation, concerns about support and desired pace, and complexity of life. Demographic disadvantages and age-related transitions were related to greater desire for disengagement, support, and stability. Elders who were married and healthy were more likely to report a desire for an energetic life-style. Results are discussed in terms of implications for future research on elders' goals as a context for understanding the meaning of self-evaluation and environmental influences on aging.

Framing the construct of life satisfaction in terms of older adults' personal goals.

Older adults' life satisfaction can be better understood in light of their personal goals. This study of 179 elders examined (a) how goals correlate with satisfaction, (b) whether elders maintain satisfaction by accommodating goals to past losses, and (c) how correlations between satisfaction and key predictors differ among groups with different goals. Satisfaction was related positively to social maintenance and energetic life-style goals and negatively to concerns for improvement, disengagement, stability, and reduced activity. Past losses were correlated with current goals but not with satisfaction, consistent with the notion of accommodation. A cluster analysis identified 5 patterns of goals: high demand, age prescribed, self-focused, socially engaged, and low demand. Correlations between satisfaction and other predictors differed by cluster, suggesting that the determinants of elders' satisfaction depend on personal goals.

The transition to junior high school: a longitudinal study of self-esteem, psychological symptomatology, school life, and social support.

This research examined the psychological well-being of 159 white and black students during the transition to junior high school. Adjustment patterns were found to be complex and highly differentiated. Self-esteem was unchanged from the end of sixth through the middle of seventh grades, rising by the end of seventh grade. Girls reported an increase in depressive and other symptoms over time relative to boys. Perceived quality of school life plunged. Peer social support increased only for blacks of high academic competence. Although there were no race differences on overall self-esteem, multivariate analyses of symptom data revealed that blacks reported greater distrust of the environment than they reported negative internal states, whereas whites reported the opposite pattern. The discussion emphasizes the developmental and ecological context of the transition.

Multiple roles, social networks, and women's well-being.

In contrast to earlier approaches to the study of multiple roles, our research was concerned with the frequency and conditions under which both positive and negative outcomes occur. Using data from a random sample of 235 married female nurses, we focused on marital and job satisfaction as important criteria of success in managing multiple roles. In the first phase of the research, a cluster analysis identified five different profiles of marital and job satisfaction. Of the two most positive profiles, one was defined by high scores in both areas, the other by high job satisfaction but only moderate marital satisfaction. In two other profiles, women were very dissatisfied with one role and at best moderately satisfied with the other. In the second phase, the profiles were found to be meaningfully associated with measures of psychological symptomatology and overall life satisfaction. The third phase considered how the profiles were linked to measures of social support and social rejection provided by five key network members. The strongest univariate profile discriminator was the level of work rejection from the spouse. A discriminant function analysis revealed that the level of spouse's work rejection was even more powerful when it was compared to the level of work rejection received from the next closest family member (typically the mother).

Social networks and adult social identities: profiles and correlates of support and rejection.

The growth of interest in social networks has underscored the need for integrative analyses of network dimensions. A three-pronged strategy to achieve this objective was pursued in a study of 261 married women nurses. First, network variables related to important adult social identities were differentiated. Factor analyses revealed four network interaction factors: work support, work rejection, general support, and general rejection. An additional factor analysis differentiated work associates from nonwork network members. Second, cluster analysis of these factor scores identified five different network profiles. The profiles differed in the importance of the woman's work to her nonwork ties as well as the frequency and pattern of different positive and negative interactions. Third, individuals with these contrasting network profiles differed on levels of life satisfaction and psychological symptomatology. The discussion emphasizes social network differences within the broader context of the ecology of human development.

Social environmental predictors of children's adjustment in elementary school classrooms.

Relationships between qualities of the perceived social environment and children's adjustment were examined in 30 second- to fourth-grade classrooms. Based on Moos' conceptual framework, social environment was assessed from both teachers' and children's perspectives. There was little agreement between the two views. Nine teacher- and peer-rated adjustment variables were used as criterion measures in multiple regression analyses which controlled for the potential confounding influence of grade level and family income. The main substantive findings were that peer sociometric ratings were more positive at lower grade levels and in classes rated by children as high in Order and Organization; teachers rated less acting-out behavior in classes seen by children as high in Affiliation, Teacher Control, and Task Orientation; and teachers rated children as more likeable in classes seen by Children as high in Teacher Control and Competition. Implications of the study's findings for future primary preventive efforts to engineer health-promoting classroom environments are discussed.