Who receives Ryan White CARE Act services? A demographic comparison of CARE act clients and the general AIDS population.

This study examines the extent to which health and social service providers funded by the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act serve women, minorities, and other vulnerable populations emphasized by the legislation. Demographic characteristics of AIDS-diagnosed clients served by CARE Act-funded providers in four metropolitan areas and two states are compared with Centers for Disease Control and Prevention estimates of AIDS prevalence. Clients of CARE Act-funded providers tend to reflect the demographics of local HIV/AIDS epidemics. Where differences exist, CARE Act clients are more likely to be women and minorities and less likely to be injecting drug users. CARE Act-funded providers are effectively reaching most medically underserved populations.

Consistency in maintaining contact with HIV-related service providers: an analysis of the AIDS Cost and Services Utilization Study (ACSUS).

Patients (n = 1949) infected with HIV were recruited for the AIDS Cost & Service Utilization Survey (ACSUS) from ten U.S. cities and administered face to face interviews at three month intervals over an 18 month period from March 1, 1991 to August 31, 1992. The interview was designed to obtain information at each wave of data collection on the use of the following services: ambulatory care, hospitalization, emergency room use, support groups/counseling, drug and alcohol treatment, and dental care. Patients were found to be highly consistent in their patterns of utilization across time, regardless of the service in question. Of the patients who reported using an emergency room (ER) at Time 1, 52% also reported using an ER during the next three months later at Time 2. Of those who reported having been hospitalized during the Time 1 reporting period, almost 58% reported a hospitalization again at Time 2. Next, use of a service at Time 6 (n = 1404, 72.2%) was regressed onto whether the person received the service at Time 2 and the personal, financial, and medical variables. Except for dental services, utilization of a service one year in the past (Time 2) was the strongest predictor of Time 6 use. The findings indicated that the one factor consistently related to service use within this sample is a factor (as opposed to education, race, or even insurance) that is amenable to intervention: previous use of that service. The individuals studied established patterns of service utilization that are of reasonably long duration once they began use of a service. This continuity of care becomes more critical as the initiation of treatments begins with the diagnosis of HIV rather than AIDS. Findings suggest that HIV outreach efforts be targeted to increasing early use of medical and behavioral services in ambulatory care settings.

A typological approach to the study of rural HIV service delivery networks.

Despite the rapid growth of AIDS cases in nonmetropolitan areas, little is known about the characteristics and needs of HIV-positive rural residents or how rural areas are responding to the epidemic. This paper proposes a typology for distinguishing among rural environments and examining variations in HIV service networks. The typology identifies three dimensions that have a major effect on the development of rural HIV service networks: degree of rurality, the prevalence of AIDS, and the epidemiological and demographic characteristics of the infected populations. Data from four case studies are used to illustrate how variations in rural environments can affect the organization and delivery of HIV/AIDS care. The typology contributes to public policy discussions by identifying key attributes of rural environments that influence program planning and implementation and the transferability of service delivery models.

Movement patterns of persons with HIV receiving treatment in public clinics in the Southern Health Region, Puerto Rico.

PIP: A survey conducted among 187 HIV-infected patients from publicly supported HIV clinics in the Puerto Rican Southern Health Region (SHR) failed to substantiate health planners' concern that this group travels frequently to the US to receive medical services. Respondents were questioned about all places of residence and all sites of HIV treatment in the past 12 months. Movement was defined as being anywhere outside of the SHR for 2 weeks or longer. 7% of the sample had moved at least once in the past year; 4% had moved outside the SHR but within Puerto Rico, while 3% had been in the continental US. Compared to the heterosexual risk group, intravenous drug users and men who have sex with men were 7-8 times more likely to have moved. The attainment of at least a high school education was also significantly and independently associated with increased probability of movement. Medical care was not identified by any of these respondents as the primary reason for travel. 58% indicated they were in their current place of residence to be near family, friends, and relatives. Both the small sample size and the low socioeconomic status of respondents may have limited the ability of this study to identify the so-called "air bridge," however.^ieng

Ensuring the dissemination of Cancer Control Demonstration Projects for Farmers.

The successful dissemination of the Cancer Control Demonstration Projects for Farmers depends not only on the effectiveness of the grants funded under this program but also on factors external to the grants. In this article, three health-related external factors are examined: the cancers amenable to prevention and control, intervention methodologies, and the organization of rural health care. Changes between 1989 and 1996 in each of these factors and the effects of these changes on the dissemination of grantee findings to public health and medical practitioners are described. Suggestions are offered on actions that the National Institutes for Occupational Safety and Health can undertake to increase the likelihood of adoption of grantee findings.

Creating an agenda for research and evaluation: HIV service delivery, the Ryan White CARE Act, and beyond.

HRSA, AHCPR and NCAP convened a working meeting in November 1992, to discuss creation of a national agenda for research and evaluation on HIV service delivery systems that are cost-effective, responsive to the needs of the diverse populations affected by the epidemic, and reflective of the lessons learned so far. In this article, the interests and goals of the conveners are described, the meeting's process and outcomes are discussed, and the nine key study areas that were identified and chosen by the meeting participants are presented. It is hoped that this article will stimulate further interest among private and public funders and among the research community in fostering the implementation of HIV service delivery-related research and evaluation studies. If this is accomplished, decision-makers will be better enabled to make informed and responsive policy decisions.

Delivery of oral health care through the Ryan White CARE Act to people infected with HIV.

The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990 was passed by Congress "to improve the quality and availability of care for individuals and families with HIV disease." The act targets those individuals infected with HIV who lack financial resources to pay for care. While provision of oral health care is not mandated by the legislation, many oral health services are supported through five different programs receiving CARE Act funding. Legislative mandates, program guidance materials, grant applications, and other related materials were reviewed to analyze oral health care services supported or proposed through the CARE Act. In fiscal year 1991, an estimated $5.8 million of the total CARE Act funds ($229.6 million) were used for oral health care, and there is evidence that oral health concerns will receive increasing attention by grantees in future years. Opportunities exist for local oral health professionals to become involved in CARE Act programs and in the priority development process. It is possible that CARE Act grantees will serve as catalysts for the development of partnerships between private practitioners and public sector programs--relationships that could lead to improved access and quality of care for people with HIV infection.

States' responses to Title II of the Ryan White CARE Act.

Title II of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990 provides formula-based grants to States to help them improve the quality, availability, and organization of health care and support services for people with human immunodeficiency virus (HIV) infection. This article reviews State expenditures during the first year of CARE Act funding (April 1991-March 1992) within the context of Title II guidelines and the federally funded grant programs that preceded and helped shape Title II. The authors also discuss future challenges that require development of resources, the assessment of program impact, and the evaluation of the quality and appropriateness of HIV-related services. Ninety-one percent of the $77.5 million awarded to States during fiscal year 1991 went for the provision of medical and support services through HIV care consortia, drug reimbursement programs, home and community-based care programs, and health insurance initiatives. The remaining monies were used for planning, evaluation, and program administration. Forty States allocated $38.9 million for the establishment of HIV care consortia to assess service needs and to develop comprehensive continuums of health and support services in the areas most affected by HIV disease. Fifty States allocated an additional $28.3 million for the continuation or expansion of FDA-approved drug therapies for low-income people with HIV infection. Twenty-five States allocated $2.2 million for the provision of home- and community-based health services, and 16 States allocated $1.3 million for programs that help low-income people with HIV infection to purchase or maintain health insurance coverage.

Legislative interventions to increase access to screening mammography.

Although numerous studies have established that breast cancer mortality can be significantly reduced through early detection, only a small percentage of women obtain screening mammograms at intervals recommended by the National Cancer Institute, the American Cancer Society, and other major medical organizations. This paper examines the importance of cost as a barrier to routine screening and the state legislative movement to make screening mammography a basic health insurance benefit. Mammography "knowledge, attitudes, and behavior" studies offer conflicting findings on the extent to which cost enters into the decision to have a mammogram. Women seldom report cost as a major reason for postponing or failing to have a mammogram; yet, descriptive studies show a consistently positive relationship between income and mammography use. State mammography reimbursement laws vary greatly with respect to whether screening mammography is a required or optional benefit, payment limits, and eligibility and referral requirements. Although state-specific data on the percentage of women with private health insurance are not available, 1987 National Medical Expenditure Survey estimates for U.S. Census geographic divisions suggest that the New England, East North Central, West North Central, Middle Atlantic, and Mountain states have the highest percentages of women who are privately-insured and, thus, potentially eligible for legislated mammography benefits. Access to screening mammography also is likely to be influenced by the proportion of employer-sponsored health plans that are self-insured and, therefore, exempt from minimum benefit mandates and the extent to which women are aware of the screening coverage.

Geographic and gender variations in total tobacco use.

This study is the first to provide complete information on prevalence rates by gender and geographic variation for each type of tobacco product used in the United States. Results indicate that, in nearly half of all states, total tobacco use in men exceeded 40% and, in four states, exceeded 50%. In women, only Nevada, Kentucky, and Michigan reported prevalence exceeding 33%. Results also indicate, however, that concurrent use of multiple tobacco forms is relatively rare. Substantial regional variation in male total tobacco use was evident, with southern males exhibiting the highest prevalence rate (44.6%). As a result, this region represents a target group in special need of comprehensive and effective tobacco use interventions.

Developing cancer control capacity in state and local public health agencies.

In 1986, the National Cancer Institute began a major grant program to enhance the technical capabilities of public health departments in cancer prevention and control. This effort, commonly referred to as "capacity building" for cancer control, provided funding to support eight State and one local health department. The program focused on developing the knowledge and skills of health department personnel to implement intervention programs in such areas as smoking cessation, diet modification, and breast and cervical cancer screening. The grants ranged from 2 to 5 years in length, with funding of $125,000 to $1.6 million per grant. The total for the program was $7.4 million. While the priorities set for these grants were nominally similar, their capacity building activities in cancer prevention and control evolved into unique interventions reflecting the individual needs and priorities of each State or locality. Their experiences illustrate that technical development for planning, implementing, and evaluating cancer prevention and control programs is a complex process that must occur at multiple levels, regardless of overall approach. Factors found to contribute to successful implementation of technical development programs include* commitment of the organization's leadership to provide adequate support for staff and activities and to keep cancer prevention and control on the organizational agenda,* the existence of appropriate data to monitor and evaluate programs,* appropriately trained staff,* building linkages with State and community agencies and coalitions to guide community action,* an established plan or process for achieving cancer control objectives,* access to the advice of and participation of individual cancer and health experts,* an informed State legislature,* diffusion of cancer prevention and control efforts,and* the ability to obtain funds needed for future activities.

Recommendations for mammography in Pennsylvania.

Recommending a mammogram represents the first step in reducing breast cancer mortality. However, additional actions may be needed to ensure lower mortality from this disease. During 1987, 2,508 breast cancer deaths were recorded in the Commonwealth. Nearly 40 percent of these deaths could have been prevented if all women followed the current screening guidelines. Regular mammograms would lead to earlier stages of diagnosis for the more than 8,000 Pennsylvanians who are diagnosed with breast cancer each year.

A comparison of problems reported by persons with cancer and their same sex siblings.

Problem reporting rates of 180 persons with cancer (PWC) were compared with those of their closest in age same sex cancer-free siblings living outside their households for the same time periods. PWC had significantly higher reporting rates for physical, activities of daily living, nutrition, and emotional problems and a significantly lower rate for family problems. Sibling problem reporting rates, which indicate the likelihood that PWC would have experienced similar problems without a diagnosis of cancer, were highest for physical, emotional, employment, and family problems suggesting that noncancer factors are especially likely to play a role in those types of problems. Regression analyses showed that female and younger PWCs tended to report more problems than their siblings suggesting that they were more affected by cancer and its treatments than were other types of PWC.

Unmet psychological, social, and economic needs of persons with cancer in Pennsylvania.

Six hundred twenty-nine persons with cancer (PWC) selected from the Pennsylvania Cancer Registry plus 397 nonprofessional (support) persons involved in their care (SP) were interviewed to determine their views of the unmet psychological, social and economic needs of PWC. The most frequently mentioned unmet need was for help in dealing with emotional problems (estimated at 25% of PWC state-wide). Other unmet need estimates ranged from 14% for financial to 4% for transportation, with 59% of PWC reporting at least one unmet need. Characteristics of PWC reporting unmet needs included being younger, a history of emotional problems, a chronic illness in addition to cancer, more advanced stage at diagnosis, and a diagnosis of lung cancer. The percent of PWC and CP reporting unmet needs were very similar. These findings indicate that more effective screening for psychosocial problems and referral to supportive services is needed.

Beliefs, social normative influences, and compliance with antihypertensive medication.

We explored the relationship between beliefs and social normative influences and self-reported hypertension medication compliance using questionnaire items based on the belief intention model of Ajzen and Fishbein. Persons for whom antihypertensive medication had been prescribed were asked to agree or disagree with statements about taking their medicine. Respondents were a subset of participants in a 1980 survey of risk factors for heart disease in two Pennsylvania counties. Highly significant differences between compliant and noncompliant individuals were observed for all items except one referring to cost. A stepwise multiple logistic regression analysis was performed with age, sex, and the belief and social normative items as independent variables, and reported compliance as the dependent variable. Three variables, age, "taking my blood pressure medicine as the doctor told me would not be necessary when my blood pressure is normal," and "your family wants you to take your blood pressure medicine as the doctor told you," entering into the equation in that order, significantly improved discrimination between compliant and noncompliant persons. The questionnaire's success may have resulted from moving beyond assessing participant's knowledge or beliefs about hypertension in the abstract to ascertaining the direct relevance of these beliefs to their taking their medicine.