Limiting the spread of HIV/AIDS in Sierra Leone: opportunities for intervention.

The global pandemic of HIV/AIDS is at catastrophic levels in sub-Saharan Africa, while the need for research and treatment initiatives throughout the developing world remains critical. The West African country of Sierra Leone is representative of both of these facts. The purposes of this study were to assess the HIV-related knowledge, attitudes, and behaviors of adult Sierra Leoneans to determine what type of HIV prevention efforts are needed in this population and to determine how such efforts could be developed and implemented. Interviews with 487 adults residing in the capital city of Freetown, Sierra Leone, and in the Northern Province of that country revealed HIV/AIDS-related knowledge, attitudes, and behaviors that reflect the impact of culture and tradition on the spread of HIV/AIDS. The challenges for HIV prevention raised through this study indicate the need to examine in greater depth the culturally specific use of traditional healers and traditional theater as channels of information that could serve to make HIV prevention initiatives more effective in Sierra Leone.

Factors affecting health status in African Americans living with HIV/AIDS.

This study surveyed face-to-face 111 African American newly diagnosed and living with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) from the Washington D.C. area, to ascertain the use of, and need for, early intervention services. The survey instrument included sections on demographics, level of health functioning and health indicators, social and financial support, and needed services. This article constructs a health status proxy variable from survey items and examines its relationship to biological and social variables. Variables found to have a significant relationship with health status are gender, type of health insurance, employment, receiving Social Security Disability Income, and level of education. A log-linear model for selection of parsimony found that the type of health insurance was most highly predictive of health status, when controlling for other variables. Persons who receive Medicaid report no better levels of health status than those without health insurance. Having private health insurance is associated with a 5.3-fold greater chance of having good or excellent health status.

Identification of the factors associated with compliance to therapeutic diets in older adults with end stage renal disease.

OBJECTIVE: To identify theory based factors pertinent to compliance with therapeutic diets. DESIGN: A paper and pencil survey was read to volunteer hemodialysis patients in outpatient dialysis clinics. SUBJECTS: A convenience sample of 276 hemodialysis patients aged 50 years and older who agreed to be interviewed during treatment. STATISTICAL ANALYSIS: Descriptive statistics were used to report responses to all survey questions. The Fisher exact test was used to test associations between the dependent variable, dietary compliance, and independent variables, which included knowledge, perceived severity of illness, attitudes toward compliance, environmental factors, perceived barriers, self-efficacy, and perceived health benefits. Principal Components Analysis determined final scale items. Logistic regression was used to develop a model of independent variables profiling the compliant patient. RESULTS: Subjects were more likely to be compliant if they indicated favorable attitudes toward compliance (P =.0076), a supportive environment (P =.0107), and knowledge about their diet (P =.0014). A logistic regression model of compliance indicated that subjects who followed their special diets were more likely to have higher knowledge (odds ratio [OR] = 1.092, 95% CI = 1.006, 1.186), perceived fewer barriers (OR = 1.094, 95% CI = 0.841, 1.226), being white race (OR = 0.710, 95% CI = 0.399, 1.263), and having gout (OR = 9.349, 95% CI = 1.139, 76.714). APPLICATION: Health professionals should apply these findings in providing dietary education focused on improving not just knowledge, but attitudes and family support. Nutrition education and health promotion applications geared to non-white populations could be particularly important as tools to improve dietary compliance.

Developing a video intervention to model effective patient-physician communication and health-related decision-making skills for a multiethnic audience.

The ENDOW study is a multisite, community-based project designed to improve decision-making and patient-physician communication skills for midlife African-American, white, and Hispanic women facing decisions about hysterectomy. Based on results of initial focus groups, a patient education video was developed in English and Spanish to serve as the centerpiece of various interventions. The video uses community women to model appropriate decision-making and patient-physician communication skills. Women in the target populations rated the video as useful to very useful and would recommend it to others. The use of theory-driven approaches and pilot testing of draft products resulted in the production of a well-accepted, useful video suitable for diverse populations in intervention sites in several states.

Perceptions of alternative therapies available for women facing hysterectomy or menopause.

Women's perceptions of alternative therapies available for managing symptoms related to menopause and to the need for hysterectomy were explored. Data are reported from 17 focus groups of peri- and menopausal aged women (n = 82) living in two southern U.S. coastal counties. Analysis showed that emergent themes did not vary by race or surgery experience. Herbal preparations, vitamin supplements, "healthy living" (diet & exercise), and mind/body practices (prayer & "mental healing") were mentioned as possible alternatives for managing symptoms. Participants more frequently identified "other" conventional medical approaches--prescription medication, laser surgery, dilation and curettage, and "watchful waiting"--as alternatives to hysterectomy. Alternative therapies are linked to women's desire to gain control over their own health care decisions and practices.

Assessing the HIV prevention capacity building needs of community-based organizations.

Community-based organizations (CBOs) have been providing HIV prevention services to priority populations for many years. Recent research suggests that CBOs could benefit from capacity building to strengthen their public health prevention knowledge and skills, including ability to access and use behavioral science to guide prevention efforts. A cross-sectional survey of 316 CBOs was conducted to assess desire and preferences for training, support for training at the organizational level, motivation for training at the individual level, barriers to training, and factors associated with the perceived need for training. Results suggest the need for a national training initiative to increase CBO capacity.

The role of male partners in women's decision making regarding hysterectomy.

Although hysterectomy is a frequently performed surgical procedure, little is known about how women make decisions regarding hysterectomy. This report details the women's perceptions of male partners' knowledge and attitudes about hysterectomy and the role women expect or allow men to play in their decision-making process. Seventeen focus groups were conducted with a total of 82 African American and Caucasian women aged 30-65 years in two coastal counties of South Carolina. Transcripts were coded and analyzed using the nonnumerical unstructured data indexing searching and theory building (QSR NUD*IST) software program. Results indicate that women perceive men to be not well informed or knowledgeable about hysterectomy, to be concerned about the quality of sexual relations after hysterectomy, and, in some cases, to be neutral about hysterectomy. African American women reported that men hold more negative perceptions about hysterectomized women. Caucasian women stressed men's inability to understand what a woman is going through and men's concern with the hysterectomy's effect on their own egos. Nonhysterectomized women felt that men would be more bothered by a surgical procedure that left more visible effects (such as mastectomy). These women defined a limited role for men in their decision making regarding hysterectomy, consisting of discussion and offering of support/sympathy, but they reserved the actual decision for themselves. In a few instances, women accorded men a role in the hysterectomy decision based on a religious interpretation of marriage. Intervention programs are recommended that target women and their partners together, using hysterectomized women and their partners as peer educators.

Talking about hysterectomy: the experiences of women from four cultural groups.

As part of the Ethnicity, Needs, and Decisions of Women (ENDOW) project, in-depth qualitative interviews and focus groups were conducted at four sites, Alabama, New Mexico, South Carolina, and Texas. In South Carolina and Alabama, African American and white women were interviewed. In Texas, African American, Caucasian, and Hispanic women were interviewed, and in New Mexico, focus groups with Caucasian, Hispanic, and Navajo women were conducted. The Texas site also conducted focus groups with lesbian women. Data were collected on women's experiences with and attitude toward menopause, hysterectomy, and hormone replacement therapy (HRT). Information also was gathered on women's concerns and what experiences they have had or expect to have with healthcare providers and what they perceive their friends', families', and sexual partners' attitudes are toward hysterectomy. Numerous commonalties of experience existed across racial and ethnic groups. Overall, the women who participated believed that doctors do not take the time to explain issues related to menopause, hysterectomy, and HRT. Most of the women who have had a hysterectomy were satisfied with the outcome of surgery, as painful symptoms were relieved. There are also several interesting differences among the groups. Decision-making patterns differed among the ethnic groups, as did experience with healthcare providers. Many women in the focus groups expressed mistrust of or negative opinions of healthcare providers. African Americans expressed mistrust of their motives for recommending surgery, as did several of the Caucasian, non-Hispanic women. Most of the Hispanic participants respected and trusted their providers. All groups said they would seek additional medical opinions if they could afford to do so.

Aspects of motivation of a volunteer AIDS care team program.

The South Carolina AIDS Care Team Program, directed by The Ecumenical AIDS Ministry, a component of the South Carolina Christian Action Council, provides emotional and supportive services to people living with HIV and AIDS. A sample of volunteer care team members participated in five focus groups as part of a process evaluation. Care teams were asked to participate based on years since training (new vs. experienced), race (white vs. African American), and location (urban vs. rural). Volunteers were motivated to become involved in a care team through previous contact with a person with AIDS, a general sense of altruism, and influences from their faith community. Due to the emotionally demanding nature of the work, motivation to remain a volunteer was also examined. It was discovered that a support system, the expression of faith, support of their faith community, and coping with the death of a care partner were essential elements for sustaining care team involvement. The implications of this study are useful to volunteer programs through faith communities to meet the growing need of people living with HIV and AIDS.

Support for school-based sexuality education among South Carolina voters.

A random-digit dialed telephone survey was conducted in a traditionally conservative southern state to determine the level of support for sexuality education in the public schools including support for specific sexuality education topics, the earliest grade level at which each topic should be taught, and the amount of instruction time required for sexuality education in the high schools. Survey data were obtained from 534 South Carolina registered voters in late January/early February 1997. Results demonstrated that most South Carolina registered voters: 1) supported sexuality education in the public schools; 2) supported instruction on a variety of sexuality education topics; 3) supported instruction at all grade levels, especially beginning in middle school; and 4) believed instruction time for sexuality education in the high schools should either remain the same or be increased. In addition, a significant increase in support for sexuality education occurred from the beginning of the survey to the end, suggesting that the instrument itself may have served as an educational tool for respondents. The characteristics of registered voters who supported sexuality education at the beginning of the survey and at the end were examined and compared. These results may assist in the development of educational and marketing strategies designed to build support for school-based sexuality education programs in South Carolina and elsewhere.

Violence against women in Sierra Leone: frequency and correlates of intimate partner violence and forced sexual intercourse.

Violence against women is a significant public health problem which impacts women, men, and children. Little is known about the frequency or correlates of violence against women in Africa. In this cross-sectional study, we found that 66.7% of 144 women surveyed in a study of AIDS knowledge, attitude, and behaviours, report being beaten by an intimate male partner and 50.7% report having ever been forced to have sexual intercourse; 76.6% of women report either forced sex or intimate partner violence. Circumcised women were most likely to report intimate partner violence and forced sexual intercourse. To improve the health of women worldwide, violence against women must be addressed.

Primary care physicians and barriers to providing care to persons with HIV/AIDS.

Primary care physicians play an increasingly important role in the care of persons with HIV/AIDS due to the rising number and changing geographic distribution of persons infected with HIV/AIDS. The study explored the relationship between barriers to health services and the experience and willingness of primary care physicians to care for persons with HIV/AIDS. The study was based on a random survey of primary care physicians in South Carolina. The results indicate that although primary care physicians' willingness to treat persons with HIV/AIDS is significantly associated with many self-reported barriers (i.e., financial, structural, knowledge, and attitudinal), their HIV/AID care experience was most significantly correlated with self-reported knowledge that overrides financial and structural barriers. The results emphasize the importance of programs and policy initiatives aimed at enhancing the primary care physicians' knowledge level and improving their attitudes related to HIV/AIDS.

Evaluation of South Carolina's HIV/AIDS community long-term care Medicaid waiver: cost comparison and patient satisfaction.

South Carolina's HIV/AIDS community long-term care Medicaid (Section 2179) waiver is evaluated via cost comparison and patient satisfaction measures. The waiver offers personal care aids, adult day care, counseling, home meals, hospice, private-duty nursing, and foster care supervision in addition to regular Medicaid services. Services to 111 eligible individuals and 52 individuals pending eligibility are evaluated by five methods. A cost comparison is conducted by comparing the cost per patient eligible day of the waiver recipients with those of a comparable group of HIV/AIDS Medicaid patients who did not participate in the waiver. The waiver services are shown to cost less than services delivered to comparable recipients. Costs per patient eligible day were $35.68 and $68.56 for the waiver patients and non-waiver patients, respectively. Telephone surveys, focus groups, provider compliance reviews, and patient record reviews were used to assess patient satisfaction and quality of care. Waiver patients were satisfied with the program overall and with the service managers who are responsible for coordinating services. Problems are identified with personal care aid performance and TB testing for health care providers. A shortage of dentists willing to see waiver patients and delays in the eligibility process are also identified. In spite of small problems, the South Carolina's HIV/AIDS community long-term care Medicaid waiver program is considered a success.

Sexual and AIDS-related knowledge, attitudes and behaviors of adolescents in sierra leone, west Africa.

A survey of 307 Sierra Leonean adolescents between the ages of thirteen and nineteen was assessed to determine their sexual and AIDS-related knowledge, attitudes, and behaviors. Results indicate high sexual activity rates among the sampled group; 89 percent of the males and 68 percent of the females had engaged in sexual intercourse. The mean age at first sexual intercourse was found to be 14.4 years for males and 15.1 years for females. Sixty-five percent of the males and 35 percent of the females reported having three or more sexual partners over their lifetime. Other findings included high rates of STDs and HIV/AIDS, low reported condom use, low reported use of other birth control methods, and low knowledge scores concerning pregnancy prevention, HIV/AIDS and STDs. Implications of these findings are discussed.

Rural physicians: a survey analysis of HIV/AIDS patient management.

Primary care physicians in South Carolina were asked about their knowledge, attitudes, beliefs, and services provided to HIV/AIDS patients. The study focused on conditions under which physicians would provide additional services in an effort to develop more effective state policies regarding HIV/AIDS. There was a 66 percent (597/900) response rate. This analysis focuses on a group of 338 physicians that identified themselves as rural (nonurban) physicians. Of the rural physicians responding, 42 percent had not treated a case of HIV/AIDS during the last year and 52 percent had seen only 1 to 9 patients. They identified lack of specialty back-up support, likelihood of losing patients, legal and ethical issues, and lack of community services as the primary barriers to service. Gaps in rural physician knowledge included when to refer HIV/AIDS cases to specialists and information on legal and ethical issues. They, like their urban colleagues, would provide additional services to HIV/AIDS patients with specialty back-up (57 percent), better community and social services support (54 percent), additional training (48 percent), and limited liability (47 percent). The authors conclude that policy changes addressing these areas in the broader contexts of rural health issues would expand access to care for persons with HIV infection in rural states.

Correlates and consequences of early initiation of sexual intercourse.

This cross-sectional analysis of the 1991 CDC Youth Risk Behavior Survey explored factors associated with an early age at first sexual intercourse. Almost 18% of White males, 49% of Black males, 5% of White females and 12% of Black females were sexually active before age 13. Carrying a weapon to school, fighting, and early (< age 13) experimentation with cigarettes and alcohol were associated with early initiation of sexual activity for all four race and gender groupings. Those initiating sexual activity early had greater numbers of partners but were 50% less likely to use condoms regularly and were two-seven times more likely to have been pregnant or caused a pregnancy. Females who initiated sexual activity early were more likely to have had a sexually transmitted disease (STD). Interventions to postpone sexual activity need to be tailored to the ethnic and gender differences observed in these analyses. Interventions must begin before age 13 and should be comprehensive school-based efforts.

PIP: The 1991 CDC Youth Risk Behavior Survey is a statewide survey of 1509 White male, 1234 Black male, 1479 White female, and 1256 Black female public school students in grades 9-12 conducted February-May 1991 in South Carolina. Survey data were used in the study of factors associated with experiencing first sexual intercourse at younger than age 13. Students younger than 14 years old were excluded from the analysis. 17.8% of White males, 49.2% of Black males, 5.1% of White females, and 11.9% of Black females had had sexual intercourse before age 13. 38% of White males, 12% of Black males, 47% of White females, and 27% of Black females were virgins at the time of the interview. Controlling for race, males were 6.8 times more likely than females to have had first sexual intercourse when younger than 13. Fighting, experimenting with cigarettes and alcohol younger than age 13, and carrying a weapon to school were associated for all race and gender groupings with the early initiation of sexual intercourse. 54.8% of White males, however, compared to 39.3% of Black males brought weapons to school, 51.1% of White males compared to 47.0% of Black males got into a fight at school, 11.6% of White males compared to 5.3% of Black males smoked before age 13, and 39.0% of White males compared to 30.6% of Black males drank alcohol before age 13. Respondents who initiated sexual intercourse before age 13 had greater numbers of partners, but were 50% less likely to use condoms regularly and were two-seven times more likely to have been pregnant or caused a pregnancy. Females who initiated sexual activity early were more likely to have had a sexually transmitted disease. The authors recommend that the ethnic and gender differences observed in this study be considered when designing interventions to postpone sexual activity. Interventions must begin before age 13 and should be both comprehensive and school-based.

Rural primary care program survival: an analysis of financial variables.

This study examines the effect of financial characteristics of rural primary care programs on the probability of their continuing as federally funded entities. A randomly selected national cohort of rural primary care programs (n = 162) was used to compare financial measures of programs that were continuing and those that were noncontinuing. Financial data were obtained from 1978-1987 Bureau Common Reporting Requirements (BCRR) forms submitted to the Bureau of Health Care Delivery and Assistance of the Department of Health and Human Services as part of the requirement to receive federal grant support for the programs. The results emphasize the importance of both outside funding and increased level of self-sufficiency in the continuation of rural primary care programs. Noncontinuing programs often suffer from both a lack of self-sufficiency and a lack of outside funding, mostly from federal sources. To a lesser extent, the number of patients also affects the program's chance of continuation. From a policy perspective, government intervention is both necessary and likely if rural primary care programs are to succeed and fulfill their mission of providing primary care for the medically underserved who are primarily poor, uninsured, and unable to pay.

Perceived Barriers to HIV Prevention Among University Students in Sierra Leone, West Africa.

This article presents the results of a small pilot study of students at Fourah Bay College in Freetown, the capital of Sierra Leone, West Africa, to provide baseline data to the National AIDS Programme in planning educational interventions aimed at preventing the spread of HIV. Results of the survey indicate that barriers to HIV prevention in Sierra Leone include persistence of belief in the idea that AIDS is not real but is a conspiracy to prevent Africans from having sex or having children, an ambivalence among women students regarding sexuality issues, a lack of familiarity with the parameters of the epidemic in Africa, and a belief that condom use behavior is not amenable to change. Implications of these findings are discussed. Further research is needed to include the portion of the population that is not literate.

AIDS-related knowledge and attitudes of social workers in South Carolina.

This study examines the association between knowledge of acquired immune deficiency syndrome (AIDS) and skill among social workers in South Carolina and attitudes toward people with human immunodeficiency virus (HIV) and AIDS. A stratified random sampling method was used to obtain a representative sample of social workers in South Carolina. Findings show that AIDS-related knowledge and skill were significantly associated with improving the general attitudes of social workers toward HIV/AIDS clients. In addition to knowledge and skill-related measures, other significant covariates of attitudes include levels of contact with HIV/AIDS clients and sensitivity to minorities. As with previous studies, demographic variables such as age and gender were not found to be significantly related to variations in attitudes toward HIV/AIDS clients. Furthermore, locality of practice and supervisory position did not significantly correlate with attitudes. The implications of these findings for social services agencies are discussed.