Impact of a computer-assisted, provider-delivered intervention on sexual risk behaviors in HIV-positive men who have sex with men (MSM) in a primary care setting.

Innovative strategies are needed to assist providers with delivering secondary HIV prevention in the primary care setting. This longitudinal HIV clinic-based study conducted from 2004-2007 in a Birmingham, Alabama HIV primary care clinic tested a computer-assisted, provider-delivered intervention designed to increase condom use with oral, anal and vaginal sex, decrease numbers of sexual partners and increase HIV disclosure among HIV-positive men-who-have-sex-with-men (MSM). Significant declines were found for the number of unprotected insertive anal intercourse acts with HIV+ male partners during the intervention period (p = 0.0003) and with HIV-/UK male partners (p = 0.0007), as well as a 47% reduction in the number of male sexual partners within the preceding 6 months compared with baseline (p = 0.0008). These findings confirm and extend prior reports by demonstrating the effectiveness of computer-assisted, provider-delivered messaging to accomplish risk reduction in patients in the HIV primary care setting.

'Worse than HIV' or 'not as serious as other diseases'? Conceptualization of cervical cancer among newly screened women in Zambia.

Invasive cervical cancer is the second most common cancer among women worldwide, with approximately 85% of the disease burden occurring in developing countries. To date, there have been few systematic efforts to document African women's conceptualization of cervical cancer after participation in a visual inspection with acetic acid (VIA)-based "see and treat" cervical cancer prevention program. In this study, conducted between September, 2009-July, 2010, focus groups and in-depth interviews were conducted with 60 women who had recently undergone cervical cancer screening at a government-operated primary health care clinic in Lusaka, Zambia. Interviewers elicited participants' causal representations of cervical cancer, associated physical signs and symptoms, perceived physical and psychological effects, and social norms regarding the disease. The lay model of illness causation portrayed by participants after recent exposure to program promotion messages departed in several ways from causal models described in other parts of the world. However, causal conceptualizations included both lay and biomedical elements, suggesting a possible shift from a purely traditional causal model to one that incorporates both traditional concepts and recently promoted biomedical concepts. Most, but not all, women still equated cervical cancer with death, and perceived it to be a highly stigmatized disease in Zambia because of its anatomic location, dire natural course, connections to socially-condemned behaviors, and association with HIV/AIDS. No substantive differences of disease conceptualization existed according to HIV serostatus, though HIV positive women acknowledged that their immune status makes them more aware of their health and more likely to seek medical attention. Further attention should be dedicated to the processes by which women incorporate new knowledge into their representations of cervical cancer.

Attitudes and sociocultural factors influencing vaginal douching behavior among English-speaking Latinas.

OBJECTIVES: To describe the practice/correlates of douching among a national sample of English-speaking Latinas. METHODS: Three hundred twenty-five (325) computer-assisted telephone interviews were completed. Analyses compare ever douchers to never douchers and identify correlates of douching. RESULTS: Of respondents, 50% had ever douched; 15% douched at least monthly. Douching practices among respondents were similar to those of other groups. Age at sexual debut was the strongest correlate of ever douching. Regular douching significantly increased as the perceived benefits of douching and the number of sources recommending douching increased. CONCLUSIONS: Interventions to prevent douching and to support cessation should be tailored to characteristics and perceptions of Latinas. Targeting secondary audiences may prove valuable.

A 15-minute interactive, computerized condom use intervention with biological endpoints.

BACKGROUND: Brief face-to-face-behavioral interventions have been shown to be efficacious, but are costly to sustain and to widely disseminate. This study evaluated the efficacy of a 15-minute theory-based behavioral intervention designed to increase condom use and reduce new cases of Neisseria gonorrhoeae and Chlamydia trachomatis. METHODS: Participants were randomly assigned via the computer to the intervention or the comparison group stratified by gender and their baseline stage of change (motivational readiness) for using condoms consistently (100%) with their main partners. Behavioral data and biologic specimens for testing of Neisseria gonorrhoeae and Chlamydia trachomatis were obtained at baseline and at 6 months post intervention. The intervention was delivered via an audio, multimedia, computerized application that provided individualized interventions to patients based on their responses to assessment items; comparison patients interacted with a 15-minute, computerized, multiple health risk assessment with no intervention. RESULTS: The majority of the sample (N = 430) was black (88%); 54.5% women; with a mean age = 24.5. Assuming all participants who did not return to the clinic at 6 months were not using condoms consistently, 32% of the treatment group versus 23% in the comparison group reported consistent condom use (P = 0.03). The combined Neisseria gonorrhoeae and Chlamydia trachomatis incidence declined to 6% in the intervention group versus 13% in the comparison group (P = 0.04). Results from a regression analysis revealed that the only statically significant predictor of sexually transmitted diseases infection at the follow-up was group assignment (OR = 1.91, 95% confidence index = 1.09-3.34; P = 0.043). CONCLUSIONS: These findings suggest that brief, interactive, computer-delivered interventions provided at the evaluation visit increase condom use and reduce sexually transmitted diseases without putting additional burden on clinicians or staff.

The evaluation of school-based violence prevention programs: a meta-analysis.

BACKGROUND: Youth violence and related aggressive behaviors have become serious public health issues with physical, economic, social, and psychological impacts and consequences. This study identified and evaluated the characteristics of successful school-based violence prevention programs. METHODS: Twenty-six randomized controlled trial (RCT), school-based studies that were designed to reduce externalizing, aggressive, and violent behavior between the 1st and 11th grades were analyzed for assessing the effects of 5 program characteristics by comparing results of intervention groups to control groups (no intervention) after intervention using a meta-analysis. Electronic databases and bibliographies were systematically searched, and a standardized mean difference was used for analysis. RESULTS: There was no significant difference between interventions, although programs that used non-theory-based interventions, focused on at-risk and older children, and employed intervention specialists had slightly stronger effects in reducing aggression and violence. Interventions using a single approach had a mild positive effect on decreasing aggressive and violent behavior (effect size =-0.15, 95% CI =-0.29 to -0.02, p = .03). CONCLUSIONS: Unlike previous individual study findings, this meta-analysis did not find any differential effects for 4 of the 5 program characteristics. In addition, the significant effect noted was contrary to expectation, exemplifying the complexity of identifying effective program strategies. This study adds to the current literature by assessing the program characteristics of RCT studies in an effort to determine what factors may affect school-based violence prevention program success.

Depressive symptoms and interpersonal victimization among African American women attending an urban STD clinic.

OBJECTIVES: This study evaluated the association of depressive symptom levels and interpersonal victimization. The sample was comprised of 455 African American women attending an urban sexually transmitted disease clinic. Interpersonal victimization was defined as whether a woman was forced to have sexual intercourse and whether a woman was ever hit, slap or physically hurt by a boyfriend, girlfriend, or spouse in the past 12 months. METHODS: Using audio computer-assisted self-interviewing (ACASI), women responded to questions regarding interpersonal victimization and depressive symptom levels (e.g., depression, sadness, loneliness and crying in the past week). RESULTS: Results indicated that women with a history of interpersonal victimization were more likely to experience higher levels of depressive symptoms when compared with women who did not. Statistically significant differences were found for being forced to have sexual intercourse (all p's <0.0001) and ever being hit, slap or physically hurt by a boyfriend, girlfriend, or spouse in the past 12 months (p's range from 0.012 to 0.0003) with regard to each depressive symptom item. CONCLUSION: Behavioral women-focused interventions need to address mental health issues associated with risky sexual behaviors in order to be more efficacious.

HIV risk among long-haul truckers in the USA.

Long-haul truck driving has been associated with HIV risk in developing countries but little research to date has considered whether truckers in the USA may also be at elevated risk for HIV and other STIs. This multi-method qualitative study explored HIV-risk factors among regional and cross-country truck drivers who were based in the southeastern USA. Data collection methods included focus groups conducted at company hubs and over Citizen's Band (CB) radio, and key informant interviews. Results indicated that sexual opportunities and risks are greater for long-haul drivers who often travel for long periods without returning home and who may engage in 'highway sex' in the absence of a regular home-life. Structural factors that have reduced drivers' autonomy, sexual risk taking and free time while traveling include recent trucking regulations, electronic surveillance and industry-wide trends emphasizing speed and efficiency. Other factors, such as age, experience, type of employment and type of route also play a role. Further research is needed to determine if these qualitative findings can be quantified in population-based studies that also include biomarker and incidence data.

Vaginal douching and intimate partner violence: is there an association?

OBJECTIVE: This study tests the hypothesis that vaginal douching among women of reproductive age is associated with exposure to intimate partner violence (IPV). METHODS: The data source is a cross-sectional population-based sample of 2,002 women ages 18-45 in the Central Pennsylvania Women's Health Study. The survey included measures of IPV, douching behavior, and relevant sociodemographic and health-related covariates. FINDINGS: Six percent of the sample reported experiencing any type of IPV in the past year, and 23% reported douching in the past year. IPV is significantly associated with douching after controlling for sociodemographic and health-related covariates. This finding holds for women with and without current reproductive capacity. CONCLUSIONS: This is the first study to identify an association between vaginal douching and IPV. Because vaginal douching is a risk factor for sexually transmitted infections, bacterial vaginosis, and adverse pregnancy outcomes, the findings could have important implications for prevention. Further research is needed to identify the reasons why women who have been exposed to IPV are more likely to douche.

The theory of reasoned action and intention to seek cancer information.

OBJECTIVES: To evaluate the applicability of the theory of reasoned action to explain men's intentions to seek prostate cancer information. METHODS: Three hundred randomly selected African American men participated in telephone interviews. Correlational and regression analyses were conducted to examine relationships among measures. RESULTS: All relationships were significant in regression analyses. Attitudes and subjective norm were significantly related to intentions. Indirect measures of beliefs derived from elicitation research were associated with direct measures of attitude and subjective norms. CONCLUSIONS: The data are sufficiently clear to support the applicability of the theory for this behavioral domain with African American men and suggest several important areas for future research.

Toward a model of prostate cancer information seeking: identifying salient behavioral and normative beliefs among African American men.

Public health actions to improve African American men's ability to make informed decisions about participation in prostate cancer control activities have a greater likelihood of success when they are theory driven and informed by members of the target population. This article reports on formative research to evaluate the usefulness of the theory of reasoned action as a model to explain and predict prostate cancer information-seeking behavior by African American men. Fifty-two men participated in eight focus group interviews. Positive behavioral beliefs for obtaining prostate cancer information from physicians included increasing awareness of and obtaining accurate information about the disease, early detection and screening, and treatment. Negative beliefs included fear, distrust, and inconvenience. Significant others, peers, siblings, and religious leaders were identified as individuals who could influence this behavior. These findings provide additional insight into ways to reach and intervene with African American men to influence this important cancer control activity.

Provider-delivered, theory-based, individualized prevention interventions for HIV positive adults receiving HIV comprehensive care.

HIV prevention efforts are often difficult to emphasize in settings delivering comprehensive HIV care due to factors such as time constraints and differing priorities about the use of clinical time. To assist clinicians within dedicated HIV clinics to offer prevention strategies, investigators at two universities in the United States (Johns Hopkins University and the University of Alabama at Birmingham) have developed and implemented similar, audio-computerized-assisted, self-interviewing systems that have been programmed to assess individual patient risk factors and identify based on the patient's self-assessment, the patient's behavioral stage or, readiness for changing, each identified target behavior. Following the assessment, the systems provide printouts of key elements of this information along with individualized, theory-based intervention strategies to the medical provider. This paper will describe our efforts in developing provider-delivered, individualized, stage-based interventions intended to reduce high-risk behaviors among HIV-infected persons.

Sexually transmitted infections among urban shelter clients.

BACKGROUND: Sexually transmitted infections (STIs) remain common in the United States. One contributor to this persistent problem is pockets of infection among persons who may not have regular access to health care, a group that includes those who seek services at shelters. OBJECTIVE: The goals of the study were to: 1) determine the acceptability of STI testing among individuals seeking services at shelters in 2 midsized southeastern cities; 2) evaluate the prevalence of chlamydia, gonorrhea, syphilis, and HIV among these individuals; and 3) assess the proportion that subsequently learned their test results and received timely and appropriate treatment if warranted. STUDY DESIGN: Using a cross-sectional design, 430 individuals between the ages of 19 and 45 seen at 3 shelters in 2 cities were approached for participation. After completing a brief behavioral assessment, each participant provided a urine specimen for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) testing, blood for syphilis serologic testing, and an oral sample for HIV testing. RESULTS: The overall recruitment rate was 97% (96% in city A and 98% in city B). Seventy-eight percent were black with a mean age of 35.1 years. STI prevalence among those reporting sexual activity in the past 2 months was 12.9% in city A and 19.9% in city B (P = 0.04). The rate of CT in city B was significantly higher than city A (15.0% vs. 6.4%, P = 0.02); however, similar rates were found for GC (5.0% vs. 3.2%), primary and secondary syphilis (0.08% vs. 1.4%), and HIV (0.07% vs. 0.06%). Overall, 91.5% of the positive cases (89.0% in city A and 94.0% in city B) learned their test results and were successfully treated. CONCLUSION: We found that shelter clients were receptive to STI testing, even for HIV, with most positive cases notified and successfully treated.

Vaginal douche practices among black women at risk: exploring douching prevalence, reasons for douching, and sexually transmitted disease infection.

OBJECTIVE: The objective of this study was to identify douching patterns and their relation to sexually transmitted disease (STD) among black women seeking an STD evaluation. STUDY DESIGN: This study was a cross-sectional survey with biologic testing for chlamydia and gonorrhea infection. RESULTS: Of 891 participants, 46.1% were current douchers. Commonly identified reasons for douching were to cleanse after menses (65.4%) and to feel fresh (42.2%). Frequent douching was associated with douching after sex (P<0.001), to alleviate an itch (P<0.001), and to feel fresh (P<0.001). Women who douched during menses (adjusted odds ratio [AOR]=4.78; 95% confidence interval [CI]=1.13-20.13) and to alleviate an itch (AOR=3.66; 95% CI=1.00-13.41) were more likely to have a current chlamydial infection. CONCLUSIONS: Douching was common among this high-risk population of black women. Prospective studies are needed to determine the consequences of douching and any mediating effects of women's motivation for the behavior on reproductive health.

Vaginal douches and other feminine hygiene products: women's practices and perceptions of product safety.

OBJECTIVE: Use of vaginal douche products has been linked with a variety of reproductive health problems; nonetheless, the practice of douching persists. The goals of this study were to 1) determine the use of vaginal douches and other feminine hygiene products, 2) ascertain how safe women think vaginal douche products are, and 3) evaluate women's readiness to stop douching. METHODS: A random-digit-dial computer-assisted telephone survey was conducted among US women between the ages of 18 and 44. RESULTS: Of the 2,602 women interviewed, 11.8% (n = 307) engaged in regular douching (White: 9.1%; African American: 27.7%; Hispanic: 15.0%). Women who douched, compared to women who did not douche, used other feminine hygiene products significantly more often (vaginal sprays [ p < .0001], wipes/towelettes [ p < 0.01], vaginal powder [ p < 0.0001] and bubble bath for feminine cleansing [ p < 0.001]). Women who douched also were more likely than nondouchers to agree with the statement, "Douche products are safe to use; otherwise they wouldn't be on the market" (70.3% vs. 33.4%, respectively; p < 0.0001). Nearly all women (90.0%) who douched had no intention to discontinue the practice. CONCLUSION: Compared with women who do not douche, women who douche use other feminine hygiene products at a much higher rate and also believe that douche products are safe. Women who douche will remain resistant to stopping the practice without innovative interventions. Given that most women start douching in adolescence, teens should be targeted for prevention efforts.

An intervention to reduce vaginal douching among adolescent and young adult women: a randomized, controlled trial.

OBJECTIVE: The objective of this study was to evaluate an intervention to reduce vaginal douching among adolescent and young women who report douching. STUDY: This study consisted of a randomized, controlled trial of 275 primarily black adolescent and young adults aged 14 to 23 years. All women participated in 3 15-minute individualized counseling sessions. The experimental group received interventions based on their stage of readiness for ceasing vaginal douching. The comparison condition emphasized healthy eating and nutrition. The primary outcome measure was douching cessation (i.e., no douching in the preceding 3 months) at the 6-and 12-month assessment; a secondary outcome was progression through the stages of change toward douching cessation. RESULTS: Based on an intention-to-treat model, participants assigned to the douching intervention group were significantly more likely to report having stopped douching at 6 months (relative risk [RR], 1.34; 95% confidence interval [CI], 1.03-1.73) and at 12 months (RR, 1.60; 95% CI, 1.28-2.00). At baseline, 89.9% of all women reported no intention to stop douching. Also based on an intention-to-treat model, there were no differences in stage across the 2 groups at 6 months (P = 0.29); however, at 12 months, the difference between the intervention and comparison group was statistically significant (P = 0.008). CONCLUSION: Stage-matched interventions can reduce douching among adolescent and young adult women.

Prevalence of condom use errors among STD clinic patients.

OBJECTIVE: To evaluate potential associations among condom errors and gonorrhea and chlamydial infection among a population of sexually transmitted disease clinic patients. METHODS: Audio computer-assisted self-interviewing was used to conduct a cross-sectional survey with 1124 participants. Biological specimens were collected during the evaluation visit. RESULTS: A substantial proportion of participants reported condom-use errors with condom breakage statistically associated with gonorrhea infection among males at enrollment (AOR = 1.91; 95% CI: 123-2.96; P = .004). CONCLUSION: Behavioral interventions that promote consistent condom use must provide the necessary skills associated with proper condom use.

Patient decision making: strategies for diabetes diet adherence intervention.

BACKGROUND: Patient self-care is critical in controlling diabetes and its complications. Lack of diet adherence is a particular challenge to effective diabetes intervention. The Transtheoretical Model (TTM) of Change, decision-making theory, and self-efficacy have contributed to successful tailoring of interventions in many target behaviors. OBJECTIVE: The purpose of this study was to develop a diagnostic tool, including TTM measures for the stages of change, decisional balance, and self-efficacy, that pharmacists involved in diabetes intervention can use for patients resistant to a diet regimen. METHODS: A questionnaire was developed through a literature review, interviews with diabetic patients, an expert panel input, and pretesting. Cross-sectional implementation of the questionnaire among a convenience sample of 193 type 1 and type 2 diabetic patients took place at 4 patient care sites throughout the southeastern United States. Validated measures were used to collect respondent self-report for the TTM variables and for demographic and diabetes history variables. Social desirability was also assessed. RESULTS: Relationships among TTM measures for diet adherence generally replicated those established for other target behaviors. Salient items were identified as potential facilitators (decisional balance pros) or barriers (decisional balance cons and self-efficacy tempting situations) to change. Social desirability exhibited a statistically significant relationship with patient report of diet adherence, with statistically significant differences in mean social desirability across race categories. CONCLUSIONS: The TTM measures for the stages of change, decisional balance, and self-efficacy are useful for making decisions on individually tailored interventions for diet adherence, with caution asserted about the potential of diabetes patients to self-report the target behavior in a socially desirable manner. Future research directions, implications, and limitations of the findings are also presented.

Sexually transmitted disease/HIV transmission risk behaviors and sexually transmitted disease prevalence among HIV-positive men receiving continuing care.

OBJECTIVE: HIV primary care clinics offer an environment in which to deliver prevention messages and to conduct sexually transmitted disease (STD) screening. Determination of the prevalence and factors associated with risk-taking behaviors among HIV clinic attendees is needed. GOAL: The goal of this study was to describe risk behaviors and STD prevalence in males receiving HIV primary care. STUDY: Participants underwent an interviewer-administered survey and STD testing during this cross-sectional study. RESULTS: Over two thirds of study participants reported sexual activity within the prior 6 months of which 6% were infected with gonorrhea or chlamydia. Men performing insertive rectal sex were 5 times less likely to use condoms when the partner was HIV-positive (odds ratio [OR], 5.14; 95% confidence interval [CI], 1.90-13.91), whereas patients with higher CD4 counts were more likely to engage in unprotected receptive rectal sex (OR, 1.20; 95% CI, 1.02-1.42). CONCLUSION: HIV primary care clinics provide access to patients in need of HIV prevention intervention and are appropriate sites for these activities.

Vaginal douching among adolescent and young women: more challenges than progress.

The practice of vaginal douching dates back centuries. Numerous studies have shown that douching is quite prevalent and often begins during adolescence. Motivation for the initiation and maintenance of this practice appears complex, and presents challenges to the intervention efforts. The practice of douching remains controversial. Douching has been implicated in numerous adverse reproductive health outcomes such as increased risk for pelvic inflammatory disease, ectopic pregnancy, reduced fertility, and bacterial vaginosis. However, recent studies in developing countries have suggested that in certain circumstances, douching may actually be beneficial. We summarize key findings from the review of published literature and ongoing research, as well as highlight research challenges to our understanding of the role of vaginal douching in reproductive health.