On the usefulness of latent variable causal modeling in testing theories of naturally occurring events (including adolescent drug use): a rejoinder to Martin.

This paper considers the arguments raised by Martin (1982) against the methodologies used by Huba, Wingard, and Bentler (1981) and their subsequent conclusions. Several of Martin's criticisms are the result of a misreading of our paper and selective citations, whereas other criticisms were discussed in the original paper and resolved through alternate forms of data analysis. Further analyses are presented to address issues raised by Martin. Martin's arguments against latent variable models are refuted.

A comparison of two latent variable causal models for adolescent drug use.

The competing simplex (involvement) and common factor models for youthful drug use are statistically compared using causal modeling with latent variables methods in a sample of 1,634 young adolescents. Latent variables of alcohol, marijuana, and other illicit drug use were confirmed and causally interconnected in a set of states. The confirmatory factor and the simplex stage models were found to be acceptable representations of the observed data according to both statistical and psychometric criteria. The results are discussed in terms of their implications for theories of emerging lifestyles including drug use, methodology, and policy about psychoactive substances.

Determinants of sexual and dating behaviors among adolescents.

The study of adolescent sexual development has typically focused on the incidence and age of onset of particular behaviors. Recent developments in the analysis of covariance structures permit more powerful simultaneous tests of the determinants of adolescent sexual behavior. These new methods allow the assessment and evaluation of the interrelatedness between unobserved, latent constructs. Data were obtained from 183 males and 193 females ranging in age from 12 to 18 years old, selected from three birth cohorts using a stratified random sample. Eight latent constructs--Sexual and Dating Involvement, Self-Acceptance, Feminist Sex Role Attitudes, Deviant Social Network, Importance of Dating, Lack of Heterosexual Competence, Sexually Active Social Network, and Stressful Change Events--were hypothesized to explain the variance in 26 observed variables. Several causal models were tested that specified structural relationships among the latent constructs. A theoretically meaningful model was arrived at that linked the eight, error-free factors.

Do characteristics of HIV/AIDS education and training affect perceived training quality? Lessons from the evaluation of seven projects.

Initial and continuing HIV/AIDS education and training has been a critical way to bring the nation's health providers up to date on emerging developments and approaches. This study reports cross-cutting findings from seven HIV/AIDS education and training projects. Trainers described over 600 training sessions from these projects in terms of their structural characteristics and design elements, while trainees described these sessions on several dimensions related to training quality. Training characteristics were compared to trainee assessments of training quality. Using a decision-tree analytic approach for major training attributes, considerable support emerged for links between training characteristics and perceived quality of the HIV/AIDS training experience. More favorable quality ratings were associated with certain projects, the training setting, the types of trainees served by the training, the intended training impact, discussion of special populations, and training methods involving interactive learning. With increased knowledge regarding how these educational experiences relate to the ways they are perceived and processed, more targeted approaches to training design on HIV/AIDS can be developed.

Risk factors and characteristics of youth living with, or at high risk for, HIV.

Over 8,000 adolescents and young adults (4,111 males; 4,085 females) reported on several HIV-related risk behaviors during enrollment into 10 service demonstration projects targeted to youth living with, or at risk for, HIV. Distinct risk patterns emerged by gender when predicting HIV serostatus (versus unknown serostatus/negative serostatus). Males who had injection drug risk histories, had sex with an HIV positive partner, had sexually transmitted diseases, had sex with males, and/or were homeless had an inflated risk of being HIV positive. Females who engaged in sex with an HIV partner, had sex with an injection drug user, and/or had sexually transmitted diseases, were at the highest HIV risk. For both samples, engaging in sex with women reduced the likelihood of HIV positive status. Very basic information about risk factors obtained at service intake offers important information about HIV status of "high risk" youth presenting for care in community programs, as well as suggests clear risk factors for targeted preventive efforts.

Effects of HIV/AIDS education and training on patient care and provider practices: a cross-cutting evaluation.

Initial and continuing training in HIV/AIDS service provision is a critical way to enable the nation's health providers to use state-of-the-art developments and perspectives. Typically, the efficacy of HIV/AIDS training programs is evaluated using assessments administered to trainees immediately following the training. This study reports cross-cutting findings from telephone interviews conducted with 218 trainees an average of 8 months after training. Long-term training effects are examined in three domains: (a) general perspectives on HIV/AIDS; (b) health care provider service provision; and (c) changes in procedures and operations at the health care system level. The findings show the different ways that the training experience had long-term positive and observable effects in these three domains. In some cases, background characteristics and job positions predicted the specific type of reported training effects. The pattern of results suggests ways in which training methods can be targeted to specific audiences.

A model for adolescent-targeted HIV/AIDS services: conclusions from 10 adolescent-targeted projects funded by the Special Projects of National Significance Program of the Health Resources and Services Administration.

This article describes a model of service for youth living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) and youth at high risk for HIV, based on the lessons learned from a set of innovative service projects funded by the Health Resources and Services Administration Special Projects of National Significance (SPNS) Program. Although each project has a unique focus, all collectively seek to enroll youth with HIV into care through new or existing HIV service networks, and direct recruitment via street outreach and other similar methods. The use of various outreach methods tends to yield different patterns of engagement of youth in services. An ideal approach may use a combination of complementary outreach methods. Data at both the national and local levels point to five major elements that capture the innovations of the collective service model: (a) peer-youth information and dissemination; (b) peer-youth advisory groups; (c) peer-youth outreach and support; (d) professional, tightly linked medical social support networks; and (e) active case management and advocacy, for individual clients as well as the programs themselves, to link the various components together. One of the most important factors in the model's success is that youth and professionals share an equal partnership in all stages of program design, planning, and implementation. Youth and professionals each share their expertise in a dynamic process. In addition, active case management is crucial, not only to ensure that clients receive needed services, but also to ensure that the programs themselves run in a coordinated, tightly linked way. Given needs of adolescent clients and existing adult-oriented service networks, the use of active case management and the active participation of youth in the services system are critical.

Bay Area Young Positives: a model of a youth-based approach to HIV/AIDS services.

Bay Area Positives, Inc. (BAY Positives), founded by and for youth living with human immunodeficiency virus (HIV), is a peer-run, peer-based organization including the board of directors, the executive director, staff, and volunteers, and was funded in part by the Special Projects of National Significance (SPNS) Program. It responds to the unique needs of HIV-positive adolescents and young people 26 years old and younger (n = 108) and targets gay and bisexual youth, youth of color, and young women. The organization has found that when young people are brought together to help one another and to mentor their peers, living with HIV becomes more manageable. It serves as an entry point into the HIV/acquired immunodeficiency syndrome (AIDS) service system, using member advocates (peer case managers) to guide members to youth-sensitive services and to help them through the delivery system. BAY Positives' goals are to provide emotional and other support to youth with HIV and to empower infected young people to get information about and access to the services they need. Its success also depends on the ability to provide as much support and development for staff as provided to members.

Childrens Hospital Los Angeles: a model of integrated care for HIV-positive and very high-risk youth.

Childrens Hospital Los Angeles (CHLA) provides an integrated care model for youth with and at high risk for human immunodeficiency virus (HIV) infection, through a grant from the Special Projects of National Significance Program, HIV/acquired immunodeficiency syndrome (AIDS) Bureau, Health Resources and Services Administration. The project has provided outreach to 8400 youth at risk and has provided clinical services to 296 young men (16.6% HIV positive) and 352 young women (9.1% HIV positive). Situated within the Division of Adolescent Medicine at Childrens Hospital Los Angeles, the project consists of a general medical clinic for youth along with psychosocial services including case management, counseling, and related ancillary services. A key part of the model is to provide health services within a general medical clinic for youth where participation in the clinic does not serve to identify a youth to his or her peers in the waiting room as having HIV. Another key part of the model is to provide extensive outreach within the community including contacts at bars and social clubs where high-risk youth congregate, on the street, and through the social networks of youth already identified as having HIV who participate in the CHLA clinics. In the last 2 years of the program, the peer outreach component has been strengthened and peer support activities have also been implemented. The program also has developed a Computer-Assisted Adolescent Referral System (CAARS), available on diskette and on the Internet, for the referral of youth to services in the Hollywood area.

Health Initiatives for Youth: a model of youth/adult partnership approach to HIV/AIDS services.

Health Initiatives for Youth (HIFY) in San Francisco, California, is an innovative organization providing health-related services for and by young people funded in part by the Special Projects of National Significance (SPNS) Program. The HIFY Youth Health Initiative (YHI) is composed of eight youth staff and aims to bring about individual and systemic change, enhance the quality of life for human immunodeficiency virus (HIV)-positive and at-risk young people, and increase the responsiveness and youth sensitivity of organizational and community systems. Comprehensive services have been delivered to 136 young men under 25 years, 33.1% of whom are HIV positive, and 164 young women, of whom 12.2% are HIV positive. In addition, thousands of youth and young adults have received lower-intensity services through dozens of educational workshops and presentations. YHI services are implemented through a comprehensive collection of education, training, and support activities that benefit the youth staff who produce them, along with the participants who benefit from the services provided. These activities include a speaker's bureau, health and advocacy trainings, internships, return-to-work and life skills training, publications, and conferences. Regional and national findings suggest that many youth do not yet comprehend their risk for HIV infection or understand the impact of HIV on their community. In direct response to these needs, HIFY programs inform and encourage access to counseling and testing, and provide meaningful access to adolescent care, treatment, and services.

Women's steps of change and entry into drug abuse treatment. A multidimensional stages of change model.

The Transtheoretical, or Stages of Change Model, has been applied to the investigation of help-seeking related to a number of addictive behaviors. Overall, the model has shown to be very important in understanding the process of help-seeking. However, substance abuse rarely exists in isolation from other health, mental health, and social problems. The present work extends the original Stages of Change Model by proposing "Steps of Change" as they relate to entry into substance abuse treatment programs for women. Readiness to make life changes in four domains-domestic violence, HIV sexual risk behavior, substance abuse, and mental health-is examined in relation to entry into four substance abuse treatment modalities (12-step, detoxification, outpatient, and residential). The Steps of Change Model hypothesizes that help-seeking behavior of substance-abusing women may reflect a hierarchy of readiness based on the immediacy, or time urgency, of their treatment issues. For example, women in battering relationships may be ready to make changes to reduce their exposure to violence before admitting readiness to seek substance abuse treatment. The Steps of Change Model was examined in a sample of 451 women contacted through a substance abuse treatment-readiness program in Los Angeles, California. A series of logistic regression analyses predict entry into four separate treatment modalities that vary. Results suggest a multidimensional Stages of Change Model that may extend to other populations and to other types of help-seeking behaviors.

Effects of women-sensitive, long-term residential treatment on psychological functioning of diverse populations of women.

A number of studies have found that women who abuse substances enter treatment with greater psychological problems and more vulnerabilities than men. This article reports on a 5-year study of clients in a comprehensive, residential drug treatment program for women and their children. Psychological assessments on 362 women included the Basic Personality Inventory (BPI), the Center for Epidemiologic Studies Depression Scale (CES-D), and the Luria-Nebraska Neuropsychological Battery, Screening Test (LNNB-ST). Early in the course of treatment, the typical client tends to experience a great deal of distress, as evidenced by scores on the CES-D. Other assessments indicate she is relatively alienated, mistrustful of others, and resentful of rules imposed on her by others. Repeated assessments show that these psychological indicators improve significantly as the client progresses through the treatment program. Additional studies are needed to focus on long-term treatment outcomes of women in programs designed specifically for them.

Predicting substance abuse among youth with, or at high risk for, HIV.

This article describes data from 4,111 males and 4,085 females participating in 10 HIV/AIDS service demonstration projects. The sample was diverse in age, gender, ethnicity, HIV status, and risk for HIV transmission. Logistic regression was used to determine the attributes that best predict substance abuse. Males who were younger; HIV positive; homeless; involved in the criminal justice system; had a sexually transmitted disease (STD); engaged in survival sex; and participated in risky sex with men, women, and drug injectors were most likely to have a substance abuse history. For females, the same predictors were significant, with the exception of having an STD. Odds ratios as high as 6 to 1 were associated with the predictors. Information about sexual and other risk factors also was highly predictive of substance abuse issues among youth.

Evaluation of a linked service model of care for HIV-positive, homeless, and at-risk youths.

Two instruments were used to evaluate an agency's type and availability of services for HIV-positive and at-risk adolescents, and to assess opinions concerning healthcare referral patterns. These instruments were administered to representatives of 22 agencies from 10 categories of healthcare services. Nonmetric multidimensional scaling was used to model ratings of interagency knowledge, referral patterns, and general satisfaction with services. We found that no agencies offered youth services for inpatient adolescent-specific mental health treatment or short-term residential drug treatment; however, few offered long-term residential substance abuse detoxification services (5%), outpatient drug maintenance (5%), HIV-specific inpatient services (9%), intensive day treatment for substance abusers (9%), HIV home care (14%), HIV hospice care (14%), inpatient medical services (14%), short-term shelters (14%), long-term housing (18%), HIV-specific clinical trials (18%), and dental services (23%). Barriers to expanding care included lack of funding, transportation, and lack of awareness among youths about services. A multidimensional scaling analysis identified a tight service cluster of two community health centers and the largest public hospital serving poor communities of color, as well as a relatively tight cluster of three service agencies located on the Boston Common serving homeless youths. A third service cluster consisted of two university-affiliated medical centers and one community health center. In conclusion, we found that many critical services for HIV-positive youths are relatively scarce. Multidimensional scaling provides a visual presentation of the relationships of network sites. This evaluation of services indicates a need for increased, accessible youth-oriented HIV services and suggests that linkages across the three distinct clusters of service providers should be solidified. These methodologies can be used to develop a generic model describing the stages of linkage formation in HIV care service networks.

Change in perceived barriers and facilitators to treatment among women with HIV/AIDS as a function of psychosocial service utilization.

Using a repeated assessment of 185 women with HIV in three national service demonstration projects that focus on reducing barriers to care, self-reported barriers to obtaining services decreased significantly over time. At the earliest time asked, participants scored an average of 5.23 on a measure of barriers to obtaining care. At the most recent time asked, they scored an average of 4.05 on the barrier measure. In a subsample of 122 women with HIV, it was found that self-reported facilitators to obtaining services increased significantly over time. At the first time asked, participants scored an average of 8.40 on a measure of facilitators to receiving services. At the most recent time asked, they scored an average of 8.98 on the facilitator measure. Results are discussed in terms of implications for designing services to minimize barriers and maximize facilitators to care for people living with HIV/AIDS.

Building comprehensive HIV/AIDS care services.

This article presents the experiences of three innovative programs for HIV/AIDS-related health care funded by the Health Resources and Services Administration (HRSA) Special Projects of National Significance (SPNS) Program. The Comprehensive Healthcare projects were funded as part of a larger initiative for innovative HIV service delivery models, consisting of 27 grantees, the funding agency (HRSA), and an Evaluation and Dissemination Center. These projects--the University of Nevada School of Medicine's Early Nutrition Intervention in HIV and AIDS project, the University of Vermont and State Agricultural College's Rural HIV Service Delivery project, and Washington University School of Medicine's Helena Hatch Special Care Center for Women--have developed specialized medical care models within the context of a continuum of services in a medical clinic. This article serves to describe the initial experiences of these three service demonstration projects, and some of the lessons learned as a result of their implementation. All of these projects share the goal of providing integrated services, such as medical care, nutrition, case management, and social and mental health services to people living with HIV/AIDS. However, the projects target different populations, (e.g., those in rural areas versus those in a large inner city), and use contrasting service delivery models of comprehensive HIV care. These projects have undertaken diverse activities and have used numerous effective strategies to increase their ability to provide a continuum of care and services for people living with HIV/AIDS. Based on the valuable lessons that the Comprehensive Healthcare projects learned during the first 2 years of funding, a number of collective recommendations have been made. It is expected that these suggestions will prove extremely useful to other programs that consider offering comprehensive health-care services to people living with HIV/AIDS or other complex medical conditions.

Evaluation of the impact and acceptance of a nutrition program in an HIV community clinic.

The present paper describes the evaluation of a nutrition service and research model for human immunodeficiency virus (HIV)-positive clients within a community based HIV acquired immune deficiency syndrome (AIDS) medical clinic. This program was designed to develop an effective, practical, replicable model for the delivery of nutrition services in the ambulatory HIV care setting. The objectives of evaluating the model were to define the ways that nutrition services in HIV/AIDS impacted clients, the clinic, and referral sources, and to continually refine the model by determining what services provide greatest benefit to clients, especially in view of the changing landscape of HIV therapy. Four evaluation activities completed during the study period of 5 years are described. These included a focus group and semistructured interview with clients, a semistructured interview with workers from the local network of service referral agencies and a client satisfaction survey at study "close-out." These evaluation processes confirmed or prompted programmatic modifications that improved access, confidentiality, and the relevance of specific components for clients. Providers/stakeholder's concerns were addressed through more frequent communication about clients' specific nutrition issues, clearer and easier referral and cooperation in recruiting patients. Also, the evaluation activities provided a platform for the communication of general and specific information about the program and for outreach. Although clients' and workers' priorities differed in some details of program implementation, there was strong agreement on the value of addressing nutrition concerns in HIV. Favorable feedback about the program gave impetus to continue nutrition services in the clinic after the project period ended and supports its application in other sites and settings.

Healthcare provider characteristics and perceived confidence from HIV/AIDS education.

This study reports findings from six training projects designed to keep health providers up-to-date on emerging developments and approaches in HIV/AIDS care. Participants were 3,779 individuals who described themselves, their professional background, and their specific experience in the HIV/AIDS field. These characteristics were compared with their self-reported confidence in managing clients, counseling clients, providing services, and the training topics. A repeated-measures design examining level and change of confidence showed little support for links between provider characteristics and confidence due to HIV/AIDS training experience. Thus, knowing a provider's background does not necessarily provide diagnostic information about who might most benefit in improved confidence from HIV/AIDS educational training. These results suggest that HIV/AIDS training programs may be targeted broadly-to a wide range of healthcare providers of diverse backgrounds-with little or no impact on overall levels and changes in provider confidence.

Service use patterns of youth with, and at high risk for, HIV: a care typology.

This paper uses confirmatory structural equation models to develop and test a theoretical model for understanding the service utilization history of 4679 youth who received services from 10 national HIV/AIDS demonstration models of youth-appropriate and youth-attractive services funded by the Special Projects of National Significance (SPNS) Program, HIV/AIDS Bureau, Health Resources and Services Administration. Although the projects differ from one another in the areas of emphasis in their service models, each is targeted to youth at high risk for HIV, or those youth who have already contracted HIV. Collectively, the projects represent a comprehensive adolescent HIV service model. This paper examines the characteristics of the services provided to young people ranging from outreach to intensive participation in medical treatment. Major typologies of service utilization are derived empirically through exploratory factor and cluster analysis methods. Confirmatory structural equation modeling methods are used to refine the exploratory results using a derivation and replication strategy and methods of statistical estimation appropriate for non-normally distributed service utilization indicators. The model hypothesizes that youth enter the service system through a general construct of connectedness to a comprehensive service model and through service-specific methods, primarily of outreach or emergency services. Estimates are made of the degree to which a comprehensive service model drives the services as opposed to specific service entry points.

Key elements for implementing comprehensive health care models for persons with HIV: a stakeholder analysis.

A semistructured interview was conducted with 69 stakeholders in three university-based health care projects that were funded to provide an integrated continuum of care for persons living with HIV/AIDS. Data from the key informant interviews yielded composite indicators of familiarity with the service model, the importance of the elements in the service model, and the perceived quality of services provided by these innovative HIV service demonstration projects. Ratings of service quality were related to ratings of the respondent's knowledge of the service demonstration project, the importance of the various elements in the service continuum, and several indicators of stakeholder characteristics using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). The groups of stakeholders most likely to give the highest quality or success ratings for these projects are identified. The implications of these findings for developing collaborative and comprehensive service models for persons with HIV/AIDS are discussed.