Using experiential training to enhance health professionals' awareness of patient compliance issues.

PURPOSE: To educate health care practitioners about medication compliance by having them play the role of patients who have been placed on a medication regimen. METHODS: In 1988, ten physicians and ten nurses working in the Acquired Immune Deficiency Syndrome Clinical Trials Unit of Tulane University and Louisiana State University participated in a compliance protocol designed to enable them to better understand the experience of their patients, who were involved in a three-year controlled trial of azidothymidine (zidovudine) for asymptomatic persons infected with the human immunodeficiency virus. Over the three-year trial, the patients were expected to take three pills five times a day at four-hour intervals every day. To gain experiential understanding of this prolonged, intensive medication regimen, the physicians and nurses agreed to follow their patients' pill-taking schedule by using placebos for seven days, and they kept diaries of their reactions to the seven-day experience. Two years later, a follow-up assessment was done to ascertain the participants' opinions about whether the seven-day experience had had a lasting, positive influence on the way they addressed compliance issues with patients. RESULTS: The primary barriers to medication compliance recorded by the participants were time-related difficulties in following such a strict, unvarying schedule (e.g., frustration at having to repeat the pill-taking five times a day at regular intervals). Other frequently recorded difficulties were social barriers to public pill-taking (e.g., being stigmatized as ill or different). The follow-up results indicated that the participants felt that the seven-day experience was a relatively fast, painless, and helpful means of educating themselves about the problems their patients face. CONCLUSION: By playing the role of patients, the physicians and nurses learned to recognize sources of patient noncompliance with medication regimens, and, as the follow-up indicated, they were able to generalize the role-playing experiences to later interactions with patients.

Barriers to human immunodeficiency virus related risk reduction among male street prostitutes.

Two hundred eleven male street prostitutes between the ages of 18 and 51 years were interviewed and tested for antibodies to the human immunodeficiency virus (HIV). Economic, social, and emotional barriers to the reduction of HIV-related risk behavior were examined within the context of several concepts present in the Health Belief Model (HBM). Three lifestyle factors were found to function as barriers to engaging in risk reduction behavior. Subjects who were more economically dependent on prostitution, perceived less control over the hustling encounter, and reported increased pleasure from sexual activity with their customers were more likely to engage in risk-taking behavior. Prostitutes' perception of the severity of HIV infection was not significantly associated with their risk behavior. Unexpected findings indicated that increases in perceived susceptibility to HIV and perceived benefit of condom use for HIV prevention were significantly related to increased risk-taking behavior. Practical applications of findings in the design and implementation of future HIV-related preventive health education programs are discussed.

PIP: A survey of male street prostitutes in New Orleans, Louisiana, on the social, economic, and psychological barriers to human immunodeficiency virus (HIV)-related risk reduction behaviors has significant implications for the design of health education programs. The 211 subjects, ages 18-51 years, were tested for HIV antibodies and interviewed through use of a semi-structured schedule aimed at eliciting data on life-style and based on the Health Belief Model. 37 (17.5%) of study subjects were HIV-positive. HIV risk behavior was measured on the basis of participation in anal-genital and oral-genital sex, sexual orientation, and syphilis serostatus. High-risk behavior was found to be significantly positively associated with economic dependence on hustling, enjoyment of sex with tricks, and perceived control over hustling, negatively with frequency and quantity of substance abuse. These variables accounted for 6%, 3%, 4% and 4%, respectively, of the total variance in risk behavior. 96% of male prostitutes identified HIV as a serious condition; however, risk-taking behavior was found to increase with increased levels of perceived susceptibility to HIV infection. Finally, risk-taking behaviors increased along with increased in perceptions of the availability and efficacy of condoms. These findings suggest that health education efforts based on promoting HIV infection as a serious condition or emphasizing the effectiveness of condom use will be ineffective without attention to the social context of population groups at greatest risk of HIV infection. Measures most likely to reduce HIV-taking behaviors among male prostitutes are, according to these findings, elimination of the economic incentive for engaging in unsafe sex through the provision of alternative income sources, empowering male prostitutes to exert control over the hustling situation, and promotion of achievement of sexual pleasure through safe sex.

Sexual behavior patterns of customers of male street prostitutes.

Information about male customers of male prostitutes, including sociodemographic and life-style characteristics, sexual and drug use behaviors, and knowledge about HIV infection were collected from a convenience sample of 211 male street prostitutes and a convenience sample of 15 male customers as part of a feasibility study. Data from these two groups indicate that despite knowledge of HIV infection and its transmission, customers engage in high-risk sexual and drug use behaviors with prostitutes. Because there is a high HIV infection rate within the male prostitute sample (175/1000) and because these customers for the most part describe themselves as bisexual or heterosexual, it is likely that male customers of male prostitutes serve as a vector of transmission of HIV infection to their other partners including the heterosexual population.

PIP: A sample of 211 adult male street prostitutes and a sample of 15 male customers of male prostitutes were recruited from the Greater New Orleans metropolitan area at the Louisiana State University Medical Center. The prostitutes were tested for HIV using the enzyme-linked immunosorbent assay and the Western Blot. Sociodemographic characteristics, sexual behavior patterns, drug use patterns, knowledge of safer sex, safe drug practices, and HIV transmission data were obtained by interviews. The prostitutes were equally distributed across age 25 and age 25 and IV vs. non-IV drug use. 105 were White, and 196 were Black. Educational level ranged from completion of Grade 1 to college. The customers include 8 Blacks and 7 Whites with an age range of 19-49 years. 7 had never been married, 4 were currently married, and 4 were either separated or divorced. The prostitutes were positive that at least 40% of their customers were married at the time of their encounters. 8 of the customers were bisexual. 6 saw themselves as heterosexual, while 1 identified himself as homosexual. 99% of the prostitutes indicated that they perform oral-genital sex with their customers. When the customer was the insertive partner, the prostitutes states that 46% wore a condom. When the prostitute was the insertive partner in anal sex, 67% of their customers did not request use of a condom. Almost 30% of the prostitutes perceived that customers solicited them for high-risk sexual acts. 8 of the customers reported that they never wore a condom. The other 7 customers said that they never work them with their regular sexual partner(s). 57% of the prostitutes reported using alcohol and drugs with their customer. Among IV drug-using prostitutes, 28% injected drugs and shared needles with their customers. Customers exhibited an accurate knowledge of AIDS, modes of HIV transmission, and safer sex practices, 11 customers said that they had been tested previously for antibodies to HIV. One indicated that he was HIV seropositive, 9 said that they were negative, and 1 subject had not yet received his test results.

Psychological characteristics of a sample of male street prostitutes.

Two hundred and eleven male street prostitutes were interviewed and administered the SCL 90-R psychological symptom checklist. When compared to nonpatient normals, male prostitutes exhibited significantly higher levels of psychopathology. However, when compared to adult psychiatric outpatients, male prostitutes exhibited significantly less psychopathology on all symptom dimensions of the SCL 90-R except paranoid ideation. The male prostitutes' elevated scores on the psychological symptom checklist may reflect their response to an often dangerous and chaotic environment. However, it is as likely that their psychological functioning leads them to this particular milieu.

Relationship of coping style to affective state and perceived social support in asymptomatic and symptomatic HIV-infected persons: implications for clinical management.

The authors describe the relationship of three coping styles to affective state (mood) and perceived social support in 29 human immunodeficiency virus (HIV)-infected homosexual/bisexual men between the ages of 18 and 45 years. Active-behavioral coping was significantly related to enhanced mood and greater perceived social support. Avoidance coping was significantly related to greater mood disturbance and lower social support. No relationships were found for active-cognitive coping. Recommendations for clinical management of HIV-infected persons and their traditional and/or nontraditional family follow from the findings.

The male street prostitute: a vector for transmission of HIV infection into the heterosexual world.

Two hundred and eleven New Orleans male street prostitutes were interviewed and tested for antibodies to the human immunodeficiency virus (HIV). The subjects' lifestyle characteristics and their sex and drug use practices were evaluated to determine the prostitutes' potential to function as a vector for transmission of HIV into populations with currently low infection rates. Information about the customers of the male prostitutes was also obtained from the sample. The period prevalence of HIV in the sample was 175/1000. Many of the male prostitutes reported having wives or girlfriends, some of whom were prostitutes themselves. The prostitutes perceived a majority of their male customers to be heterosexual or bisexual (indicating sexual contact with women as well as men), many (39%) were thought to be married. Results from the study support the argument that male prostitutes serve as a bridge of HIV infection into populations with currently low infection rates through contact with both non-customer sexual partners and customers and thus indirectly to spouses and sexual partners of these individuals.

Determinants of subject compliance within an experimental anti-HIV drug protocol.

A study of subject compliance within an experimental anti-HIV drug protocol was conducted with 40 asymptomatic HIV seropositive persons participating in a double-blind, placebo controlled trial of the effectiveness of ZDV. Subject compliance was assessed through the use of study nurse independent ratings. The 20 most compliant and 20 least compliant subjects were surveyed at a 6-month interval using a self-report instrument designed to assess perceived social support and other psychosocial factors thought to effect compliance. Results indicated that more adherent subjects lived further from their treatment site, did not live alone, saw their study nurse as supportive, and were more likely to depend on a significant other for a wide range of social, economic, and emotional support. Implications for the practical use of these findings are discussed and suggestions for future research are proposed.

A biopsychosocial examination of symptomatic and asymptomatic HIV-infected patients.

This study evaluated twenty-nine symptomatic and asymptomatic HIV-infected homosexual/bisexual men between eighteen and forty-five in the areas of psychiatric/psychosocial, neuropsychological, family, and immunological functioning. The subjects were referred by physicians, nurses, and mental health professionals from the Tulane/Louisiana State University AIDS Clinical Trials Unit and the C-100 outpatient Primary Care Clinic for HIV-infected patients served within the Charity Hospital of Louisiana at New Orleans. All subjects and their significant others were evaluated between November 1987 and October 1988 at the C-100 Clinic. The outcome measures were mood disturbance, psychological distress, and CD4 cell count. The most significant other family member, as selected by each subject, completed family measures. The subjects experienced psychological distress and neuropsychological problems. Active-behavioral coping appeared adaptive (related to enhanced mood) as did perceived social support (related to positive mood and lower psychological distress). Higher levels of neuropsychological functioning (verbal memory, visual memory, motor speed, and visual-motor sequencing) were associated with enhanced psychosocial functioning and/or immunological status. The findings from this study highlight the importance of conducting longitudinal studies using a multidimensional approach in which HIV-infected persons and their most significant other family members are evaluated within a biopsychosocial model.

Susceptibility to AIDS: what college students do and don't believe.

In-depth, qualitative discussion using the nominal group technique examined freshmen's perceived susceptibility to AIDS and barriers to prevention. Groups were led by dormitory resident advisors as a follow-up to a survey questionnaire of college students' knowledge and beliefs about AIDS. Students' comments showed that many misunderstandings lay behind an apparent understanding of the facts about AIDS. These findings underscore how imperative it is that college health education programs be attuned to the needs and address the deficiencies of the particular student body. In-depth, qualitative research techniques such as the nominal group are described as useful in tailoring AIDS prevention to the specific campus audience and are an appropriate introduction to an AIDS-education session. Suggestions, based on students' comments, are made for improving AIDS-prevention programs on campus.

Teenagers' beliefs about AIDS education and physicians' perceptions about them.

A survey of 189 Louisiana teenagers and 80 Louisiana family physicians revealed that the teenagers overwhelmingly preferred to learn about acquired immune deficiency syndrome (AIDS) from a physician. This result stimulated an interest in learning whether family physicians shared adolescents' opinions that they are the best teachers for AIDS education and whether family physicians understand adolescents' knowledge and beliefs about AIDS sufficiently well to be effective AIDS educators. Family physicians' responses to a questionnaire based, in part, on the Health Belief Model were compared with teenagers' responses about their knowledge, health beliefs, and preferred format and method of learning about AIDS. Results indicated that family physicians' predictions about teenagers' knowledge and beliefs about AIDS were not always accurate, but, except when physicians underestimated the teenagers' perceived obstacles to AIDS prevention, the data suggested that physicians would be effective in teaching teenagers about AIDS. Family physicians showed good agreement with teens in estimating their desired method and format for learning about AIDS, including their preference for a physician instructor.

Lay volunteers' knowledge and beliefs about AIDS prevention.

The imperative to inform the public about the risks of HIV-infection and AIDS, combined with an acute shortage of resources for doing so, has led to an unprecedented number of lay volunteers who are performing functions normally reserved for health professionals. In many communities, the general public may receive much of their information about HIV-transmission and AIDS prevention from lay volunteers who work for community-based AIDS awareness programs. Therefore, it would be of interest to know whether lay volunteers' own knowledge and beliefs about AIDS are accurate and consistent with promoting safer sex and if they are not so initially, whether they are readily amenable to change after training by health professionals. To investigate these issues, pre-/post-questionnaires were administered to lay persons in training to become volunteers for the NO/AIDS Task Force in New Orleans, Louisiana. Prior to training, lower knowledge volunteers differed from their higher knowledge peers on 2 of the 5 Health Belief Model (HBM) dimensions: perceived vulnerability (p .057) and barriers (p .002). After training, these differences disappeared, and all volunteers scored 100% on the knowledge section. Lay volunteers' opinions are also provided about where, in what format, and by whom adults and teenagers should be taught about AIDS.

A retrospective study of attitude change during medical education.

A retrospective attitude questionnaire was administered to 70 of 157 graduating seniors at the end of the medical school year. Students perceived that they became more cynical during medical education. In addition, they perceived that they were more concerned with making money, more concerned for patients, and more helpful. These findings relate to the developmental stressors of medical education as they affect the individual student. Burn-out and impairment are possible consequences; a preventive approach is advocated.

Graduating medical students' ratings of stresses, pleasures, and coping strategies.

The authors' objective in the study reported here was to gather data on the stress and coping of medical students in order to design a health promotion and wellness program. A retrospective questionnaire was completed by 71 of 157 graduating seniors. Examinations, classwork, and financial responsibilities were considered the three most stressful aspects of medical education. The most uplifting items (that is, pleasant, happy, or satisfying experiences) were recreation and social interaction, although good examination performance was rated second highest. Planful problem-solving (that is, deliberate problem-focused efforts to alter a situation) was the most frequently used form of coping, although four of the eight forms of coping assessed were used at least moderately often and all eight were used to some extent.

Comparison of the prevalence of type A behavior in boys and girls from two contrasting socioeconomic status groups.

The prevalence of Type A behavior in children from lower-class rural and upper-class urban backgrounds was compared using the Hunter-Wolf A-B Self-Rating Scale (H-W A-B). Analyses of variance were performed for two levels of socioeconomic status (SES), two levels of race (black and white), two levels of gender, and two levels of age (9-11 and 13-14). A significant difference for SES was found in the predicted direction with a greater prevalence of Type A being found among upper-urban children (p less than .001). There was also a significant effect for race (p less than .0001). Although there was a significant effect for gender with boys scoring higher (p less than .001), there was no difference between boys and girls within either SES group, and both boys and girls in the upper-urban group were more Type A than boys and girls in the lower-rural group (p less than .001). The possibility that the lack of sex differences within groups may reflect changing lifestyles for young women is discussed as a topic worthy of further epidemiological investigation.

The prevalence of type A personality in the children of alcoholics.

Three studies are reported which investigate the prevalency of an excess risk of type A personality in the children of alcoholics (COAs). Reports in the clinical literature suggest there is an excess risk of type A in COAs, but this has never been empirically demonstrated. The Matthews Youth Test for Health (MYTH) was administered to nonalcoholic mothers of 46 COAs and 65 matched controls to measure children's type A competitiveness and impatience-aggression. Results were significant only for greater impatience-aggression in COAs. In a second study, 104 COAs and controls matched for age, sex, race, and father's occupational status were rated by military fathers of intact families using MYTH. The results of the first study were not replicated for COAs, and there was no correlation between a father's Jenkins Activity Scale (JAS) score and his child's type A personality. A third study of 70 matched COAs and controls used the Hunter-Wolf A-B Rating scale, a self-rating scale for children and found no significant differences in children's type A personalities based on membership in an alcoholic family, sex, or birth order. It was concluded that the discrepancy between clinical reports and the present data may have been due to misperceptions about successful, hardworking COAs who, particularly in contrast to their more notorious siblings, may be viewed as "workaholics" and improperly labeled as type A personalities.