Development and implementation of a process evaluation for intervention quality improvement of a community-based behavioral HIV intervention trial in Tanzania.

Aim: Process evaluations for social and behavioral interventions are increasingly important as interventions become more complex and multi-faceted. Conducting process evaluations in low-resource international settings can be challenging. Process evaluations in low-resource international settings can help inform and improve quality of ongoing intervention implementation. We conducted a process evaluation of a cluster-randomized controlled trial to assess the efficacy of a microfinance and health leadership program on sexually transmitted infections and intimate partner violence perpetration among young men in Tanzania. Subject and Methods: Our trial included 1,491 participants and the intervention lasted two years. We collected process data on microfinance loan uptake and repayment, and health leaders' health conversations with peers to monitor intervention reach and dose received. We developed a database system that allowed offline data collection and synced to a central database when internet was accessible. Research staff in the U.S. accessed data from the central database to analyze and create regular implementation reports. Results: Process graphical reports facilitated identification of implementation challenges and enabled us to resolve issues before they worsened. For example, from a group with low microfinance loan repayment we learned area participants perceived the loan to be a grant, and then we clarified the misinformation with participants. Conclusions: The process evaluation helped inform ongoing intervention implementation, including approaches to improve reach and uptake of interventions. Field staff time was protected by systemizing the sharing of data processing and analyses across the global team.

The Health of Undocumented Latinx Immigrants: What We Know and Future Directions.

Undocumented Latinx immigrants experience unique factors prior to migration, during migration, and after migration that shape their health. Our review summarizes the limited but growing literature highlighting how exposure to trauma, immigration enforcement, changes to social networks, and discrimination negatively affect the mental and physical health of undocumented Latinx immigrants. We also discuss how policies and social ties can promote their health. We focus on areas of particular concern, including health care, mental health, and HIV. Future research should use interdisciplinary approaches and intersectional frameworks to understand and address health inequities. Conducting research with undocumented Latinx immigrant communities requires community engagement, assurance of confidentiality, and creative recruitment and retention strategies. Recommendations for public health practice include investing in community health centers and organizations to ensure access to health and social services; presenting results with sufficient contextualization to interpret their generalizability; and advocating for federal-, state-, and local-level policy changes that reduce the negative health consequences associated with being undocumented.

Results from a cluster-randomized trial to evaluate a microfinance and peer health leadership intervention to prevent HIV and intimate partner violence among social networks of Tanzanian men.

Despite calls to engage men in HIV and intimate partner violence (IPV) prevention efforts, effective approaches to reach and engage men in low-resource, high-HIV prevalence settings are limited. We identified and engaged social networks of mostly young men in a study designed to evaluate the efficacy of a combined microfinance and peer health leadership intervention to prevent HIV and IPV. We conducted a cluster-randomized trial among 60 social networks locally referred to as "camps" within Dar es Salaam, Tanzania. Camps were randomly assigned (1:1) to a microfinance and peer health leadership intervention or a control condition that received a brief delayed intervention after the study's conclusion. Allocation was not masked to participants or researchers. Behavioral assessments were conducted at baseline and 30-months post-intervention launch, with biological samples drawn at 30-months to test for sexually-transmitted infections (STIs). Primary outcomes included prevalence of STIs and past-year IPV perpetration. Secondary outcomes included STI sexual risk behaviors and past-year HIV testing. Proximal intervention targets included inequitable gender norm attitudes and hope. A modified Poisson regression approach was used to estimate intention-to-treat intervention effects on outcomes assessed at the 30-month follow-up. We enrolled 1,258 men within 60 camps. Of these men, 1,029 (81.8%) completed the 30-month follow-up. There were no differences by condition in STI prevalence, IPV perpetration, or sexual risk behaviors at the 30-month follow-up. Intervention participants reported greater levels of past-year HIV testing, controlling for baseline testing (aRR 1.13 95% CI 1.005-1.28). They also reported significantly lower levels of inequitable gender norm attitudes (adjusted effect -0.11, 95% CI -0.21-0.003). We successfully engaged and retained social networks of men in this multilevel intervention study. While we did not see an effect on the primary outcomes, our intervention successfully improved HIV testing and reduced inequitable gender norm attitudes.

Using Syndemics Theory to Examine HIV Sexual Risk Among Latinx Men Who Have Sex with Men in Philadelphia, PA: Findings from the National HIV Behavioral Surveillance.

Latinx men who have sex with men (MSM) continue to be disproportionately impacted by HIV/AIDS. Identifying the role of multiple syndemic factors associated with sexual risk behaviors is imperative in order to develop effective prevention and treatment strategies. Cross-sectional data for this study were derived from three cycles of the Philadelphia portion of the National HIV Behavioral Surveillance System. This study explored the impact of syndemic factors - heavy drinking, exchange sex, and homophobic discrimination - on sexual HIV risk behaviors, operationalized as number of male partners, and condomless anal intercourse (CAI) with main and casual partners among Latinx MSM (n=464). Analyses took two forms: a syndemic approach, using the cumulative number of conditions as an independent variable; and a non-syndemic approach, incorporating each condition as a unique factor. In multivariable syndemic analyses, participants with two or more factors reported more male partners and more CAI casual male partners than those with none. In non-syndemic models, homophobic discrimination and exchange sex were significantly positively associated with total number of male partners, while heavy drinking was associated with more casual CAI partners. Quantitative results indicate that syndemic and non-syndemic approaches vary in their relative capacity to account for sexual risk among Latinx MSM.

RESUMEN: Los hombres latinos que tienen sexo con hombres (HSH) continúan siendo desproporcionadamente afectados por el VIH / SIDA. Identificar el papel de múltiples factores sindémicos asociados con las conductas de riesgo sexual es imprescindible para desarrollar estrategias efectivas de prevención y tratamiento. Los datos transversales para este estudio se derivaron de tres ciclos de la parte de Filadelfia del Sistema Nacional de Vigilancia del Comportamiento del VIH. Este estudio exploró el impacto de los factores sindémicos (consumo excesivo de alcohol, sexo de intercambio y discriminación homofóbica) en los comportamientos sexuales de riesgo de VIH, operacionalizados como el número de parejas masculinas y las relaciones anales sin condón (IAC) con parejas principales y casuales entre los HSH latinos (n = 464). Los análisis tomaron dos formas: un enfoque sindémico, usando el número acumulado de condiciones como una variable independiente; y un enfoque no sindémico, que incorpora cada condición como un factor único. En análisis sinádicos multivariables, los participantes con dos o más factores informaron más parejas masculinas y más parejas masculinas casuales CAI que aquellos sin ninguno. En los modelos no sindémicos, la discriminación homofóbica y el intercambio sexual se asociaron significativamente positivamente con el número total de parejas masculinas, mientras que el consumo excesivo de alcohol se asoció con parejas CAI más casuals. Los resultados cuantitativos indican que los enfoques sindémicos y no sindémicos varían en su capacidad relativa para dar cuenta del riesgo sexual entre los HSH latinos. PALABRAS CLAVE: Conductas de riesgo sexual del VIH, Latinos gays y bisexuales, Condiciones sindémicas, Consumo de alcohol de alto riesgo, Intercambio de sexo, Homofobia.

Engaging Young Men as Community Health Leaders in an STI and Intimate Partner Violence Prevention Trial in Dar es Salaam, Tanzania.

BACKGROUND: This article presents lessons learned from a microfinance and health intervention for young men designed to prevent sexually transmitted infections (STI) and intimate partner violence (IPV) in Dar es Salaam, Tanzania. We describe the different strategies we used to identify and train young men to become change agents within their social networks. DESCRIPTION: A cluster-randomized trial with 60 camps was undertaken in the Kinondoni District of Dar es Salaam. A total of 170 members from 30 intervention camps were trained in March 2014 as popular opinion leaders (POLs), whom we call Camp Health Leaders (CHLs). We describe the process of nominating, training, and retaining CHLs. We also describe our monitoring process, which included the collection of weekly diaries assessing topics discussed, number of peers engaged in conversations, reactions of peers, and challenges faced. LESSONS LEARNED: POLs within naturally existing social networks can be engaged in STI and IPV prevention initiatives. Continuous efforts in retention, such as holding community advisory board (CAB) meetings, developing prevention slogans and t-shirts, and offering small grants to POL teams for intervention activities, were important to keeping POLs engaged in the intervention. Further, booster-training sessions were critical to maintain the message of the project and ensure that the challenges POLs face with implementing the programs were addressed in a timely manner. CONCLUSION: Recruiting POLs in a Tanzanian urban setting and engaging them in STI and IPV reduction through social networks is possible. Training POLs in health information and interpersonal communication is important. Utilizing booster sessions and a variety of retention strategies for POLs in programs that aim to reduce IPV and STI infections among young men is essential to maintain the health leaders' engagement in the intervention as well as intervention fidelity.

Microfinance and health interventions: Factors influencing loan repayment success with young men in Dar es Salaam, Tanzania.

Poverty is associated with numerous poor health outcomes. Youth unemployment in Tanzania is approximately 13.7%, and concentrates in urban areas. These youth lack relevant job skills and access to financial capital. Microfinance continues to be implemented globally to address poverty, and increasingly has been linked to health interventions. Men less frequently are recipients of microfinance loans. We offered microcredit to young men in an area of Dar es Salaam with high poverty as part of a randomised controlled-trial to assess the efficacy of a microfinance and health leadership intervention in preventing STI acquisition. We used mixed methods to understand predictors of successful loan repayment. Our qualitative sub-study showed that leader influence, prior business experience, personal motivation, and planning facilitated repayment. Using a modified Poisson approach, our quantitative analysis showed that successful repayment was associated with business experience, education, increasing number of children, community of residence, percentage of network members trained in business, and repayment success of peer leaders. Our results suggest that enforcing group accountability and repayment rules, offering ongoing training, and using successful entrepreneurs as role models could increase repayment success in similar populations. These strategies could provide financial opportunity for men while minimising risk for microfinance institutions.

Immigration Legal Services as a Structural HIV Intervention for Latinx Sexual and Gender Minorities.

Lack of legal immigration status is associated with poor HIV-related outcomes for immigrant Latinx sexual and gender minorities (LSGM). LSGM often meet eligibility criteria for legal immigration relief. A Medical-Legal Partnership (MLP) may thus be strategic to improve their health. We know little about the challenges LSGM face during the immigration legal process. We conducted in-depth interviews with six key informants and sixteen LSGM who recently applied for immigration legal relief. We coded and analyzed the data for emergent themes. Challenges to instituting an MLP for LSGM included lack of specialized training on working with SGM for immigration attorneys, and for clients: knowledge about legal deadlines, lack of housing and family support, and re-traumatizing experiences. Clients' outcomes were positive when attorneys and mental health providers collaborated. For LSGM, the benefits of immigration relief included reduced HIV risk. An MLP that addresses the surmountable challenges could improve HIV-related outcomes among LSGM.

Structural Network Position and Performance of Health Leaders Within an HIV Prevention Trial.

The effectiveness of peer leaders in promoting health may depend on the position they occupy within their social networks. Using sociocentric (whole network) and behavioral data from the intervention arm of a cluster-randomized HIV prevention trial in Dar es Salaam, Tanzania, we used generalized linear models with standardized predictors to examine the association between heath leaders' baseline structural network position (i.e., in-degree and betweenness centrality) and their 12-month self-reported (1) confidence in educating network members about HIV and gender-based violence (GBV) and (2) number of past-week conversations about HIV and GBV. As in-degree centrality increased, leaders reported fewer HIV-related conversations. As betweenness centrality increased, leaders reported greater number of conversations about GBV. Network position was not significantly associated with confidence in discussing either topic. Our results suggest that peer leaders who occupy spaces between sub-groups of network members may be more effective in engaging their peers in sensitive or controversial topics like GBV than more popular peer leaders.

Perpetration and Victimization of Intimate Partner Violence Among Young Men and Women in Dar es Salaam, Tanzania.

We describe and compare the baseline rates of victimization and perpetration of three forms of intimate partner violence (IPV)-psychological, physical, and sexual-among sexually active men ( n = 1,113) and women ( n = 226) enrolled in an ongoing cluster-randomized HIV and gender-based violence prevention trial in Dar es Salaam, Tanzania. IPV was measured using a modified version of the World Health Organization Violence Against Women instrument. We assess the degree to which men and women report overlapping forms of IPV victimization and perpetration. Sociodemographic and other factors associated with increased risk of victimization and perpetration of IPV are examined. Within the last 12 months, 34.8% of men and 35.8% of women reported any form of IPV victimization. Men were more likely than women to report perpetrating IPV (27.6% vs. 14.6%, respectively). We also found high rates of co-occurrence of IPV victimization and perpetration with 69.7% of male perpetrators and 81.8% of female perpetrators also reporting victimization during the last year. Among men, having ever consumed alcohol and experiencing childhood violence were associated with increased risk of most forms of IPV. Younger women were more likely to report perpetrating IPV than older women. We found evidence of gender symmetry with regard to most forms of IPV victimization, but men reported higher rates of IPV perpetration than women. Given the substantial overlap between victimization and perpetration reported, our findings suggest that IPV may be bidirectional within relationships in this setting and warrant further investigation. Implications for interventions are discussed.

Promoting Pre-exposure Prophylaxis to Prevent HIV Infections Among Sexual and Gender Minority Hispanics/Latinxs.

Sexual and gender minority Hispanics/Latinxs (henceforth: Latinxs) continue to be disproportionately impacted by HIV/AIDS in the U.S. Pre-exposure prophylaxis (PrEP) is a biomedical prevention approach which holds significant promise for at risk and vulnerable populations. We discuss barriers and facilitators to uptake of PrEP among sexual and gender minority Latinxs living in the U.S. through an ecosocial lens that takes into account structural, community, and individual contexts. The impact of immigration status on PrEP uptake emerges as a major and recurrent theme that must be understood and addressed by HIV prevention programs aiming to promote an inclusive strategy for sexual and gender minority Latinxs living in the U.S.

Social Network Influence on HIV Testing Among Urban Men in Tanzania.

Men in sub-Saharan Africa have low HIV testing rates. Social networks exert an important influence on men's HIV-related behavior. We examined associations between network factors and HIV testing among men in Dar es Salaam, Tanzania. Data are from the baseline assessment of an HIV prevention trial with 48 primarily male networks. Among 923 sexually active men, 52 % had ever tested for HIV. In a random effects logistic regression model, men in the network core were 1.50 times more likely (p < .05) to test than those in the periphery. Percentage of women in the network was associated with men's increased HIV testing (AOR 4.24, p < .05). Perception of network HIV stigma was negatively associated with HIV testing (AOR 0.92, p < .01). Thinking at least one close friend tested for HIV was associated with increased testing (AOR 2.66, p < .001). Social network interventions are a promising approach for scaling up men's HIV testing.

Comparing Perceptions with Actual Reports of Close Friend's HIV Testing Behavior Among Urban Tanzanian Men.

Men have lower rates of HIV testing and higher rates of AIDS-related mortality compared to women in sub-Saharan Africa. To assess whether there is an opportunity to increase men's uptake of testing by correcting misperceptions about testing norms, we compare men's perceptions of their closest friend's HIV testing behaviors with the friend's actual testing self-report using a unique dataset of men sampled within their social networks (n = 59) in Dar es Salaam, Tanzania. We examine the accuracy and bias of perceptions among men who have tested for HIV (n = 391) and compare them to the perceptions among men who never tested (n = 432). We found that testers and non-testers did not differ in the accuracy of their perceptions, though non-testers were strongly biased towards assuming that their closest friends had not tested. Our results lend support to social norms approaches designed to correct the biased misperceptions of non-testers to promote men's HIV testing.

Evidence of social network influence on multiple HIV risk behaviors and normative beliefs among young Tanzanian men.

Research on network-level influences on HIV risk behaviors among young men in sub-Saharan Africa is severely lacking. One significant gap in the literature that may provide direction for future research with this population is understanding the degree to which various HIV risk behaviors and normative beliefs cluster within men's social networks. Such research may help us understand which HIV-related norms and behaviors have the greatest potential to be changed through social influence. Additionally, few network-based studies have described the structure of social networks of young men in sub-Saharan Africa. Understanding the structure of men's peer networks may motivate future research examining the ways in which network structures shape the spread of information, adoption of norms, and diffusion of behaviors. We contribute to filling these gaps by using social network analysis and multilevel modeling to describe a unique dataset of mostly young men (n = 1249 men and 242 women) nested within 59 urban social networks in Dar es Salaam, Tanzania. We examine the means, ranges, and clustering of men's HIV-related normative beliefs and behaviors. Networks in this urban setting varied substantially in both composition and structure and a large proportion of men engaged in risky behaviors including inconsistent condom use, sexual partner concurrency, and intimate partner violence perpetration. We found significant clustering of normative beliefs and risk behaviors within these men's social networks. Specifically, network membership explained between 5.78 and 7.17% of variance in men's normative beliefs and between 1.93 and 15.79% of variance in risk behaviors. Our results suggest that social networks are important socialization sites for young men and may influence the adoption of norms and behaviors. We conclude by calling for more research on men's social networks in Sub-Saharan Africa and map out several areas of future inquiry.

Documentation Status as a Contextual Determinant of HIV Risk Among Young Transgender Latinas.

PURPOSE: The purpose of this study was to explore the contextual factors that determine or mitigate vulnerability to HIV among Latina transgender women. Documentation status (legal authorization to live in the United States) has been cited by other studies as a barrier to recruitment or engagement in HIV-related care among immigrant Latinos, but not explored as a determinant of HIV risk for transgender immigrant Latinas. METHODS: We collaborated with a community-based organization to explore these contextual, including social and structural, factors. In-depth interviews in Spanish captured life histories of eight 18- to 29-year-old transgender Latinas, who collectively self-identify as chicas trans. Codes were assigned deductively from the interview guide, and emerging themes were identified throughout data collection. RESULTS: Most participants migrated to the United States from Central America after experiencing discrimination and violence in their countries of origin. Participants emphasized documentation status as a critical factor in three areas related to social and structural determinants of HIV risk: gender identity expression, access to services, and relationship power dynamics. Chicas trans who gained legal asylum reported greater control over sexual relationships, improved access to services, and less risky employment. CONCLUSIONS: Documentation status emerged as a key HIV risk factor for this population. For undocumented transgender Latinas, legal asylum appears to be a promising HIV-related protective factor. Further research could assess whether legal assistance combined with wraparound support services affects HIV prevention for this population.

Young Men's Social Network Characteristics and Associations with Sexual Partnership Concurrency in Tanzania.

Social network influence on young people's sexual behavior is understudied in sub-Saharan Africa. Previous research identified networks of mostly young men in Dar es Salaam who socialize in "camps". This study describes network characteristics within camps and their relationship to young men's concurrent sexual partnerships. We conducted surveys with a nearly complete census of ten camp networks (490 men and 160 women). Surveys included name generators to identify camp-based networks. Fifty seven percent of sexually active men (n = 471) reported past year concurrency, measured using the UNAIDS method. In a multivariable model, men's individual concurrency was associated with being a member of a closer knit camp in which concurrency was the normative behavior. Younger men who had older members in their networks were more likely to engage in concurrency. Respondent concurrency was also associated with inequitable personal gender norms. Our findings suggest strategies for leveraging social networks for HIV prevention among young men.

An Empirical Analysis of the Impact of Recruitment Patterns on RDS Estimates among a Socially Ordered Population of Female Sex Workers in China.

Respondent-driven sampling (RDS) is a method for recruiting "hidden" populations through a network-based, chain and peer referral process. RDS recruits hidden populations more effectively than other sampling methods and promises to generate unbiased estimates of their characteristics. RDS's faithful representation of hidden populations relies on the validity of core assumptions regarding the unobserved referral process. With empirical recruitment data from an RDS study of female sex workers (FSWs) in Shanghai, we assess the RDS assumption that participants recruit nonpreferentially from among their network alters. We also present a bootstrap method for constructing the confidence intervals around RDS estimates. This approach uniquely incorporates real-world features of the population under study (e.g., the sample's observed branching structure). We then extend this approach to approximate the distribution of RDS estimates under various peer recruitment scenarios consistent with the data as a means to quantify the impact of recruitment bias and of rejection bias on the RDS estimates. We find that the hierarchical social organization of FSWs leads to recruitment biases by constraining RDS recruitment across social classes and introducing bias in the RDS estimates.

From coitus to concurrency: sexual partnership characteristics and risk behaviors of 15-19 year old men recruited from urban venues in Tanzania.

Understanding the uptake and patterns of sexual partnerships of adolescent males reveals their risky behaviors that could persist into adulthood. Using venue-based sampling, we surveyed 671 male youth ages 15-19 from an urban Tanzanian neighborhood about their sexual partnerships during the past 6 months. The proportion of males who had ever had sex increased with age (21 % at age 15; 70 % at age 17; 94 % at age 19), as did the proportion who engaged in concurrency (5 % at age 15; 28 % at age 17; 44 % at age 19). Attendance at ≥2 social venues per day and meeting a sexual partner at a venue was associated with concurrency. Concurrency was associated with alcohol consumption before sex among 18-19 year olds and with not being in school among 15-17 year olds. We find that concurrency becomes normative over male adolescence. Venue-based sampling may reach youth vulnerable to developing risky sexual partnership patterns.

Social venues that protect against and promote HIV risk for young men in Dar es Salaam, Tanzania.

Developing effective place-based health interventions requires understanding of the dynamic between place and health. The therapeutic landscape framework explains how place-based social processes and physical geography interact and influence health behavior. This study applied this framework to examine how venues, or social gathering places, influenced HIV risk behavior among young, urban men in Tanzania. Eighty-three public venues where men aged 15-19 met new sexual partners were identified by community informants in one city ward. The majority (86%) of the venues were called 'camps', social gathering places that had formal leaders and members. Observations were conducted at 23 camps and in-depth interviews were conducted with 36 camp members and 10 camp leaders in 15 purposively selected camps. Geographic and social features of camps were examined to understand their contributions to men's behaviors. Camps were characterized by a geographic space claimed by members, a unique name and a democratic system of leadership and governance. Members were mostly men and socialized daily at their camp. They reported strong social bonds and engaging in health-promoting activities such as playing sports and generating income. Members also engaged in HIV risk behaviors, such as meeting new sexual partners and having sex in or around the camp at night. Some members promoted concurrent sexual partnerships with their friends and resisted camp leaders' efforts to change their sexual risk behavior. We conclude that camps are strategic venues for HIV prevention programs for young Tanzanian men. They served as both protective and risk landscapes, illustrating three domains of the therapeutic landscape framework: the built environment; identities of landscape occupants; and sites for collective efficacy. The framework and data suggest HIV intervention components might augment the protective features of the camps, while changing environmental features to reduce risk.

Well-being and family support among elderly rural Mexicans in the context of migration to the United States.

OBJECTIVE: To explore perceptions of well-being, family support, and economic resources in relation to level of contact with migration to the U.S. among a sample of elderly males from rural Mexico. METHOD: The snowballing technique was used to obtain a sample of 372 participants. Four groups were created according to the level of contact with migration among older adults and their children. RESULTS: Greater level of contact with migration was associated with a higher likelihood that an older adult was literate, married or living with someone, self-employed, and retired or pensioned. In addition, greater level of contact with migration to the U.S. was associated with a higher level of perceived well-being, family support, and economic security. DISCUSSION: Elderly, rural Mexican men with a greater degree of contact with migration to the U.S. seem to have more security and well-being in their old age.

Factors associated with potentially inappropriate drug utilization in a sample of rural community-dwelling older adults.

BACKGROUND: Many medications present special risks when used by older adults (ie, those aged > or = 65 years) and are considered potentially inappropriate for this population. The Beers criteria are often used to identify such medications. Past research has documented that use of Beers drugs is common among older adults. OBJECTIVE: The aim of this work was to examine factors associated with potentially inappropriate drug use among rural community-dwelling older adults using a conceptual framework adapted from the Andersen-Newman behavioral model of health service use. METHODS: This was a population-based, cross-sectional survey. Data were collected via face-to-face home interviews between 2002 and 2004. Rural community-dwelling older adults residing in a single county in North Carolina were eligible. Potentially inappropriate drug use was operationalized using the Beers criteria. Data concerning predisposing (ie, age, sex, race, education, and marital status), enabling (ie, social support and insurance status), need (ie, disability and history of major depression, hypertension, osteoarthritis, back problems, or other comorbidities), and utilization factors (ie, number of medications used) were collected. RESULTS: Data were gathered from 892 people, with information on medication use available for 800. Two hundred thirteen of these 800 participants (26.6%) used > or = 1 Beers drug. Compared with individuals who used no Beers drugs, those who used > or = 1 Beers drug reported lower levels of social support (odds ratio [OR], 0.94; 95% CI, 0.90-0.99) and higher levels of disability (OR, 1.48; 95% CI, 1.11-1.97), used more medications (OR, 1.07; 95% CI, 1.01-1.13), and were more likely to have a history of major depression (OR, 1.67; 95% CI, 1.05-2.66), hypertension (OR, 1.58; 95% CI, 1.07-2.33), osteoarthritis (OR, 1.58; 95% CI, 1.09-2.29), and back problems (OR, 1.72; 95% CI, 1.19-2.47). CONCLUSION: As suggested by the Andersen-Newman model, the risk of potentially inappropriate drug use is highest among those with the greatest medication needs, as evidenced by poorer health status in this sample of rural community-dwelling older patients.