Research on street-based female sex workers documents a multitude of problems faced by these women, such as, substance use, HIV risk, mental health problems, victimization, and homelessness. The presence of problems such as these is understood as a syndemic, or co-occurrence of two or more risk factors that act synergistically to create an excess burden of disease. However, the syndemic framework has not previously incorporated the examination of resilience to understand what protective factors enable female sex workers to cope with syndemic risk. Using 562 baseline interviews from street-based African American female sex workers enrolled in a randomized intervention trial, this study is the first to investigate expressions of resilience among this vulnerable population. Specifically, these analyses examine high levels of resilience, as measured by personal mastery, in order to understand the contributions of syndemic risk factors and protective factors on the expression of resilience. In bivariate logistic regression models, women with high resilience reported significantly higher odds of high school education, greater access to transportation, and more social support, in addition to lower odds of foster care history, homelessness, substance dependence, severe mental distress, victimization, and HIV risk. In the multivariate model, higher odds of high school education and increased social support, in addition to lower odds of mental distress and HIV risk remained associated with high resilience. The findings suggest specific targets for intervention to assist female sex workers in coping syndemic risk factors and achieving better health outcomes. These include the prioritizing education and training opportunities and the enhancement of social support.
HIV infection is associated with lower health-related quality of life (HRQoL), which is influenced by immunovirological factors, negative affect, neurocognitive impairment, and functional dependence. Although apathy is a common neuropsychiatric sequela of HIV infection, emerging findings regarding its unique role in lower HRQoL have been mixed. The present study was guided by Wilson and Cleary's (1995) model in examining the association between apathy and physical and mental HRQoL in 80 HIV+ individuals who completed a neuromedical examination, neuropsychological assessment, structured psychiatric interview, and a series of questionnaires including the SF-36. Apathy was measured using a composite of the apathy subscale of the Frontal Systems Behavioral Scale and the vigor-activation subscale of the Profile of Mood States. Independent of major depressive disorder, neurocognitive impairment, functional status, and current CD4 count, apathy was strongly associated with HRQoL. Specifically, apathy and CD4 count were significant predictors of physical HRQoL, whereas apathy and depression were the only predictors of mental HRQoL. All told, these findings suggest that apathy plays a unique role in HRQoL and support the importance of assessing and managing apathy in an effort to maximize health outcomes among individuals with HIV disease.
Despite good physical prognosis, patients who receive a diagnosis of non-cardiac chest pain (NCCP) may experience persistent pain and distress. While cognitive-behavioural interventions have been found to be effective for this group, they are difficult to deliver in busy emergency department (ED) settings. Addressing the acceptability and relevance of self-help interventions is an important initial step in addressing this need. This study sought to examine the acceptability and relevance of an evidence-based self-help intervention for ED patients with persistent NCCP and anxiety. Patient (interviews:N?=?11) and specialist chest pain nurse (focus group:N?=?4) views on acceptability and feasibility were examined. Data were analysed using thematic analysis. Patients and nurses reported that there was a need for the intervention, as stress and anxiety are common among patients with NCCP, and provision of psychosocial support is currently lacking. Both patients and nurses reported that the intervention was relevant, acceptable, and potentially useful. Some changes to the intervention were suggested. Nurses reported that the intervention could be used within the existing staff resources available in an ED setting. This study represents an important first step towards developing a brief self-help intervention for ED patients with NCCP and anxiety. Further research should seek to determine the efficacy of the intervention in a pilot trial.
Alcohol and drug use contribute to the pathogenesis of diabetes and are associated with adverse health outcomes, but little research exists on treatments for substance use disorders (SUDs) in patients with diabetes. The aim of this study was to evaluate contingency management (CM) treatments targeting substance use in patients with diabetes. A secondary analysis evaluated the main and interactive effects of diabetes status and treatment condition on outcomes of 681 substance abusers. All participants were enrolled in randomized clinical trials comparing CM to standard care (SC). As in the main trials, CM treatment improved outcomes. However, there was a significant treatment condition X diabetes status interaction effect in terms of durations of abstinence achieved and proportion of negative samples submitted; patients with diabetes responded even more favorably than their counterparts without diabetes when receiving CM. Analyses of post-treatment effects revealed that patients with diabetes, regardless of the type of SUD treatment to which they were earlier assigned, were more likely than those without diabetes to be abstinent at the 9-month follow-up. The findings suggest CM may be an effective treatment for this vulnerable subgroup of substance abusing patients.
Depression and substance use, the most common comorbidities with HIV, are both associated with poor treatment outcomes and accelerated HIV disease progression. Though previous research has demonstrated short-term and follow-up success for cognitive behavioral therapy for adherence and depression (CBT-AD) on depression outcomes among patients with HIV in care (Safren et al., 2009) and among patients with HIV in active substance abuse treatment for injection drug use (IDU) (Safren et al., 2012), there is little information regarding possible moderating effects of active use versus abstinence on depression treatment gains. The present study aimed to examine recent substance use at treatment initiation as a moderator of the acute and maintenance effects of CBT-AD on depression. We used data from a two-arm, randomized controlled trial (N= 89) comparing CBT-AD to enhanced treatment as usual (ETAU) in individuals in treatment for IDU (Safren et al., 2012). To test whether depression at time of presentation affected outcomes, repeated-measures ANOVAs were conducted for two time-frames: 1) acute phase (baseline to post-treatment) (acute) and 2) maintenance phase (baseline to 12-month follow-up). To further examine maintenance of gains, we additionally looked at post-treatment to 12-month follow up. Depression scores derived from the Clinical Global Impression (CGI) for severity and the Montgomery-Asberg Depression Rating Scale (MADRS) served as the primary outcome variables. Acute (baseline-post treatment) moderation effects were found for those patients endorsing active drug use at baseline in the CBT-AD condition, who demonstrated the greatest reductions in MADRS scores at post-treatment (F1,76]=6.78,p=0.01) and follow up (F1,61]=5.46,p=0.023). Baseline substance use did not moderate differences from post-treatment to 12-month follow-up as depression treatment gains that occurred acutely from baseline to post-treatment were maintained across both patients engaged in substance use and abstainers. We conclude that CBT-AD for triply diagnosed patients (i.e., HIV, depression, substance dependence) is useful for treating depression for both patients with a history of substance use, as well as patients currently engaged in substance use.
We investigated (1) how household wealth affected the relationship between conditional cash transfers (CCT) and unconditional cash transfers (UCT) and school attendance, (2) whether CCT and UCT affected educational outcomes (repeating a year of school), (3) if baseline school attendance and transfer conditions affected how much of the transfers participants spent on education and (4) if CCT or UCT reduced child labour in recipient households. Data were analysed from a cluster-randomized controlled trial of CCT and UCT in 4043 households from 2009 to 2010. Recipient households received $18 dollars per month plus $4 per child. CCT were conditioned on above 80% school attendance, a full vaccination record and a birth certificate. In the poorest quintile, the odds ratio of above 80% school attendance at follow-up for those with below 80% school attendance at baseline was 1.06 (p?=?.67) for UCT vs. CCT. UCT recipients reported spending slightly more (46.1% (45.4–46.7)) of the transfer on school expenses than did CCT recipients (44.8% (44.1–45.5)). Amongst those with baseline school attendance of below 80%, there was no statistically significant difference between CCT and UCT participants in the proportion of the transfer spent on school expenses (p?=?.63). Amongst those with above 80% baseline school attendance, CCT participants spent 3.5% less (p?=?.001) on school expenses than UCT participants. UCT participants were no less likely than those in the control group to repeat a grade of school. CCT participants had .69 (.60–.79) lower odds vs. control of repeating the previous school grade. Children in CCT recipient households spent an average of .31 fewer hours in paid work than those in the control group (p?.001) and children in the UCT arm spent an average of .15 fewer hours in paid work each week than those in the control arm (p?=?.06).
Obesity associated cognitive impairments may be partially reversible through bariatric surgery. Depression, a prevalent comorbidity in bariatric surgery candidates, is linked with cognitive impairment and poorer surgical outcomes in other populations. No study has examined the effects of pre-operative depression on cognitive changes in bariatric surgery patients. 67 bariatric surgery patients completed a computerized cognitive test battery prior to surgery and 12-months post-operatively. The Structured Clinical Interview for theDSM-IVAxis I disorders assessed Major Depressive Disorder (MDD). Pre-surgery history of MDD was found in 47.8% of patients, but was not associated with greater baseline cognitive impairments. Repeated measures revealed improved cognitive abilities 12-months after surgery. Pre-surgery history of MDD did not influence post-operative cognitive function. Pre-operative history of MDD did not limit post-operative cognitive improvements. Larger studies with extended follow-ups are needed to clarify our findings and identify factors (e.g., older age) that may modify cognitive changes following surgery.
Age is related to less distress in several populations including people with multiple sclerosis (MS). One theory posits this is due to decreased emotional reactivity and better coping as people age and we attempted to test this theory in MS. We used a cross-sectional survey of 429 people with MS. Participants completed measures of physical and cognitive function, depressive symptoms and anxiety. Age moderated the relationship of physical function to distress such that decreased physical function was related to more distress in younger participants. Age moderated the relationship of cognitive function to depression such that decreased cognitive function was related to more depressive symptoms in younger participants. Age did not moderate the relationship of cognitive function and anxiety. The effect was only seen in women with MS, however there were fewer men in the sample. The results are consistent with the theory of decreased emotional reactivity and better coping with age. However, we were unable to test this in much older adults (75+ years of age).
Heightened psychosocial stress coupled with maladaptive coping may be associated with greater sexual risk engagement. This study examined the association between stress levels and coping strategy use as predictors of sexual risk behavior engagement over 24 months among African American adolescent females (N = 701; M = 17.6 years) enrolled in an STI/HIV risk-reduction intervention program. Participants completed audio computer assisted self-interview (ACASI) measures of global stress, interpersonal stress, coping strategy use, and sexual behaviors prior to intervention participation.?Follow-up ACASI assessments were conducted at 6-, 12-, 18-, and 24-months post-intervention. Generalized estimated equation models examined associations between baseline stress levels and coping strategy use as predictors of condom use (past 90 days, last sex) and multiple partners during follow-up. Global stress and individual coping strategy usage were not associated with differences in condom use. Higher interpersonal stress was associated with lower proportion condom use (p=0.018), inconsistent condom use (p=0.011), and not using a condom at last sex (p=0.002). There were no significant associations between stress levels, coping strategy use, and multiple partners. Future research should explore mechanisms that may underlie the association between elevated interpersonal stress and decreased condom use among this population.
Clear associations have emerged between conscientiousness and health behaviours, such that higher levels of conscientiousness are predictive of beneficial health behaviours. This study investigated the conscientiousness-fruit and vegetable consumption relationship and whether behavioural intention mediated this relationship. A large sample of adults (N?=?2136) completed an online battery of questionnaires measuring conscientiousness, behavioural intentions to consume fruit and vegetables, together with self-reported behaviour. Correlation analysis revealed that conscientiousness and each of its facets were positively associated with behavioural intention and self-reported behaviour. Hierarchical multiple regression analyses revealed that after controlling for age, gender and education, total conscientiousness, and the facets of responsibility, industriousness, order and virtue predicted self-reported behaviour. Further analysis revealed that in line with the Theory of Planned Behaviour, behavioural intention fully mediated the conscientiousness-fruit and vegetable behaviour relationship. In conclusion, low levels of conscientiousness were found to be associated with lower fruit and vegetable intentions, with the latter also associated with fruit and vegetable consumption.
Adherence to cardiac health behaviors is a critical predictor of prognosis in the months following an acute coronary syndrome (ACS). However, there has been minimal concomitant study of multiple nonadherence risk factors, as assessed via record review, structured assessments, and qualitative interviews, among hospitalized ACS patients. Accordingly, we completed an exploratory mixed methods study with 22 individuals who were admitted for ACS and had suboptimal pre-ACS adherence to physical activity, heart-healthy diet, and/or medications, defined by a Medical Outcomes Study Specific Adherence Scale (MOS SAS) score <15/18. During hospitalization, participants underwent quantitative assessments of sociodemographic, medical, and psychological variables, followed by in-depth semi-structured interviews to explore intentions, plans, and perceived barriers related to post-discharge health behavior changes. The MOS SAS was readministered at 3 months and participants were designated as persistently nonadherent (MOS SAS<15; n=9) or newly adherent (n=13). Interviews were transcribed and coded by trained raters via content analysis, and quantitative variables were compared between groups using chi-square analysis and independent-samples t-tests. On our primary qualitative analysis, we found that participants with vaguely described intentions/plans regarding health behavior change, and those who focused on barriers to change that were perceived as static, were more likely to be persistently nonadherent. On exploratory quantitative analyses, greater medical burden, diabetes, depressive symptoms, and low optimism/positive affect at baseline were associated with subsequent post-ACS nonadherence (all p<.05). In conclusion, this appears to be the first study to prospectively examine all of these constructs in hospitalized ACS patients, and we found that specific factors were associated with nonadherence to key health behaviors 3 months later. It may therefore be possible to predict future nonadherence in ACS patients, even during hospitalization, and specific interventions during admission may be indicated to prevent adverse outcomes among patients at highest risk for post-ACS nonadherence.
The purpose of this study was to examine the rates of medication adherence among HIV-infected adolescents/young adults and to explore the relationship between negative affect, cognitive ability/ formal reasoning, and substance use on the medication adherence of these youth. Forty-two HIV-positive youth (25 males, 17 females; age range 16 – 24) currently taking antiretroviral medications were recruited to participate in a one-hour interview. Using the time-line follow-back calendar method, 66% of participants had missed a dose of medicine in the past week while 42% missed a dose ‘yesterday’. Multiple regression analyses demonstrated that both depression and age of first marijuana use were statistically significant predictors of non-adherence (p< .01,R2= .326). Specifically, higher rates of depressive symptoms and younger age of first marijuana use predicted higher rates of non-adherence. Developmentally, 69% of the sample had yet to begin the transition from concrete thinking to formal or abstract reasoning. The results from this project demonstrate that adherence to antiretroviral medications continues to be a problem with HIV-infected youth. These results are an important first step toward the development of interventions aimed at increasing medication adherence among adolescents and young adults living with HIV.
Previous studies have reported that regular practice of a device-guided slow breathing (DGB) exercise decreases resting blood pressure (BP) in hypertensive patients. The performance of DGB is associated with acute decreases in sympathetic vascular tone, and it has been suggested that the decreases in resting BP produced by regular practice of DGB over periods of weeks is due to chronic decreases in sympathetic nervous system activity. However, the kidneys respond to sympathetically-mediated changes in BP by readjusting blood volume levels within a few days. Thus, the mechanism by which DGB could produce long-term BP changes remains to be clarified. Previous research with laboratory animals and human subjects has shown that slow, shallow breathing that increases pCO2potentiates blood pressure sensitivity to high sodium intake. These findings raise the possibility that deeper breathing during DGB that decreases BP might involve opposite changes in pCO2. The present study tested the hypothesis that performance of DGB acutely decreases a marker of pCO2, end tidal CO2(PetCO2). Breathing rate, tidal volume, and PetCO2were monitored before, during, and after a 15 min session of DGB by patients with elevated blood pressure. Blood pressure, heart rate, and heart rate variability (HRV) were also measured under these conditions. A control group was also studied before, during, and after a 15 min session of spontaneous breathing (SB). The DGB group, but not the SB group, showed progressive and substantial increases in tidal volume and low frequency HRV, and decreases in PetCO2and systolic blood pressure. The PetCO2effects persisted into the post-task, rest period. The findings are consistent with the hypothesis that habitual changes in breathing patterns of the kind observed during DGB could potentiate an antihypertensive adaptation via effects on pCO2and its role in cardiovascular homeostasis.
Research has documented significant relationships between sexual and gender minority stress and higher rates of suicidality (i.e., suicidal ideation and attempts) and substance use problems. We examined the potential mediating role of substance use problems on the relationship between sexual and gender minority stress (i.e., victimization based on lesbian, gay, bisexual, or transgender identity; LGBT) and suicidality. A non-probability sample of LGBT patients from a community health center (N= 1457) ranged in age 19 to 70 years. Participants reported history of lifetime suicidal ideation and attempts, and substance use problems, as well as experiences of LGBT-based verbal and physical attacks. Substance use problems were a significant partial mediator between LGBT-based victimization and suicidal ideation and between LGBT-based victimization and suicide attempts for sexual and gender minorities. Nuanced gender differences revealed that substance use problems did not significantly mediate the relationship between victimization and suicide attempts for sexual minority men. Substance use problems may be one insidious pathway that partially mediates the risk effects of sexual and gender minority stress on suicidality. Substances might be a temporary and deleterious coping resource in response to LGBT-based victimization, which have serious effects on suicidal ideation and behaviors.
Caring for children can be a source of joy and fulfilment, but also a source of stress, especially for caregivers living with illness and/or coping with difficult socio-economic conditions. Risks for poor caregiver mental health are especially salient in many parts of southern Africa affected by a generalised HIV epidemic, high rates of physical illness, difficult livelihood conditions and an increasing number of orphaned and vulnerable children in need of care. Given limited availability and low uptake of formal mental health services in South Africa, the potential protective role of informal community or ‘social’ resources for caregiver populations requires greater attention. To our knowledge, this is the first study to quantitatively assess the relationship between social support and symptomatic anxiety among caregivers of children living in HIV-endemic southern African communities. The data are from household survey interviews with 2477 adult primary caregivers of children aged 10-17 years living in two (urban and rural) resource-deprived HIV-endemic South African communities. Hierarchical logistic regression analysis with interaction terms was conducted to assess whether HIV and other illness were significant stressors for caregiver anxiety, whether social support had main or stress-buffering protective effects on anxiety, and whether gender moderated the association between social support and anxiety. Our findings showed significant main effects of social support on caregiver anxiety, but no evidence of stress-buffering effects of support or of gender moderating the support-anxiety relationship. This suggests that social support is a general mental health resource for both male and female caregivers of children in these HIV-endemic communities, regardless of whether they are facing specific stressors related to HIV or other illness. Our results highlight the importance of paying greater attention to the social environment when designing and implementing caregiver health interventions, and indicate that social support could be a valuable component of such interventions.
The latest recommendations for building dynamic health behavior theories emphasize that cognitions, emotions, and behaviors – and the nature of their inter-relationships -- can change over time. This paper describes the development and psychometric validation of four scales created to measure smoking-related causal attributions, perceived illness severity, event-related emotions, and intention to quit smoking among patients experiencing acute cardiac symptoms. After completing qualitative work with a sample of 50 cardiac patients, we administered the scales to 300 patients presenting to the emergency department for cardiac-related symptoms. Factor analyses, alpha coefficients, ANOVAS, and Pearson correlation coefficients were used to establish the scales' reliability and validity. Factor analyses revealed a stable factor structures for each of the four constructs. The scales were internally consistent, with the majority having an alpha of >0.80 (range: 0.57 to 0.89). Mean differences in ratings of the perceived illness severity and event-related emotions were noted across the three time anchors. Significant increases in intention to quit at the time of enrollment, compared to retrospective ratings of intention to quit before the event, provide preliminary support for the sensitivity of this measure to the motivating impact of the event. Finally, smoking-related causal attributions, perceived illness severity, and event-related emotions correlated in the expected directions with intention to quit smoking, providing preliminary support for construct validity.
The physician-patient relationship is important to the successful delivery of health care. Health locus of control (HLOC) of the patient, the extent to which individuals attribute their health to their own actions or to external agents, may affect the patient-provider relationship. This study examined the influences of HIV and HLOC on trust in physician among a population of predominantly minority women and their family members. Powerful others HLOC demonstrated a positive relationship with trust in physician and chance HLOC had a negative relationship with trust in physician. HIV moderated both of these relationships.
Men who have sex with men (MSM) comprise the largest risk group ofindividuals living with HIV in the United States and have the highest rates ofnew infections. A minority of HIV-infected MSM engage in unprotected analintercourse after learning about their infection, potentially transmitting thevirus to others. The current study sought to generate self-generated descriptivethemes, from a group of HIV-infected MSM who reported high rates of sexualtransmission risk behavior that may be relevant for understanding sexual risk inthis group. Five descriptive themes emerged during content analysis: a)serostatus attribution, b) assumption of sexual partner’s responsibilityfor safer-sex, c) sexual sensation seeking, d) ongoing substance use, and e)dissatisfaction with current relationships. Traditional HIV transmissionrisk-reduction interventions that have been known to have only modest effectsshould be augmented by developing HIV prevention strategies for this subgroup ofMSM to address these salient themes.
Young African American women are disproportionately affected by HIV/AIDS, STIs, and engage in greater sexual concurrency than other race/ethnicities. It is important to evaluate behaviors and characteristics associated with the risk of sexual concurrency so interventions can target factors most likely to affect positive change. An emphasis on correlates of concurrency beyond individual-level factors has been suggested. The purpose of this study therefore was to identify individual- and partner-level characteristics associated with sexual concurrency among high-risk, young African American women. Data were collected from 570 African American adolescent women (aged 15–21) recruited from a STD clinic, a family planning clinic, and a teen clinic located in Atlanta, GA from March 2002 through August 2004. Logistic regression analysis was conducted in 2012 to evaluate correlates of sexual concurrency. Results show that almost one-quarter of participants reported sexually concurrent partnerships and 28.4% suspected male partner concurrency. Logistic regression results indicated the number of lifetime sexual partners and relationship factors were the primary contributors to engaging in concurrency in this sample. These findings suggest relationship factors may be important contributors to the prevalence of sexual concurrency among young African American women. Interventions targeted toward sexual health among young African American women may need to specifically address partner/relationship factors. Through these findings we hope to better understand sexual risk taking and develop strategies that would overcome barriers to existing interventions aimed at improving the sexual health outcomes of young, African American women.