Effects of Community Health Nurse-Led Intervention on Childhood Routine Immunization Completion in Primary Health Care Centers in Ibadan, Nigeria.

Immunization coverage of vulnerable children is often sub-optimal in many low- and middle-income countries. The use of a reminder/recall (R/R) system has been one of the strategies shown to be effective in improving immunization rates. In the resent study, we evaluated the effect of R/R and Primary Health Care Immunization Providers' Training (PHCIPT) intervention on routine immunization completion among 595 infants in Ibadan, Nigeria. The design was a group randomized controlled trial with Local Government Area (LGA) being the unit of randomization. Four randomly selected LGAs were randomized to receive a cellphone R/R only (A), a PHCIPT only (B); combined R/R and PHCIPT (C) intervention or serve as a control group (D). Children aged 0-12 weeks were consecutively recruited into each group and followed up for 12 months. The primary outcome measure was routine immunization completion at 12 months of age. At the study endpoint, immunization completion rates were: group A, 98.6 %; group B, 70 %; group C, 97.3 %; and group D, 57.3 %. Compared to the control group, the cellphone R/R group was 72 % (RR 1.72, 95 % CI 1.50-1.98) and the combined RR/PHCIPT group 70 % (RR 1.70, 95 % CI 1.47-1.95) more likely to complete immunization. In contrast, immunization completion in the PHCIPT group was marginally different from the control group (RR 1.22, 95 % CI 1.03-1.45). These findings remained robust to adjustment for potential predictors of immunization completion as covariates. In conclusion, cellphone reminder/recall was effective in improving immunization completion in this Nigerian setting. Its use is recommended for large scale implementation.

Socio-demographic factors associated with childhood immunization uptake in Akinyele Local Government Area, Oyo State, Nigeria.

BACKGROUND: Immunization is an effective public health intervention for reduction of childhood mortality. The expected target coverage is 90%, however, Nigeria currently has coverage below this target and this has implications for childhood morbidity and mortality. Several reasons may account for this low coverage. The study was carried out to determine the socio-demographic factors associated with immunization completion. METHODS: This is a cross- sectional household survey that utilized multistage sampling technique. Four hundred mothers of children aged 12-24 months randomly selected from four communities were interviewed using structured questionnaire. RESULTS: Data from 383 (95.8%) participants were analysed and only 145 children (37.9%) were fully immunized. The results showed that children of mothers with secondary education or more (OR = 3.45, 95% CI = 2.11, 5.66, p < 0.001), those children whose mothers were married to their fathers (OR = 3.17, 95% CI = 1.39, 7.21, p = 0.006), children born to Christian families (OR = 1.72, CI = 1.07, 2.78, p = 0.026) and those in urban area (OR = 3.89, 95% CI = 2.24, 6.74, p < 0.001) are more likely to complete immunization. CONCLUSION: Improving female education, strengthening at risk mothers, and designing adequate public health interventions to reach families in rural locations can improve immunization uptake.

Perceived barriers to receiving HIV services in groups of traditionally underserved individuals: empirical models.

Persons living with HIV/AIDS face many issues that make them highly vulnerable to a number of health and social problems. As the demographics of the epidemic have shifted in recent years, many members of traditionally underserved groups have encountered barriers to entering the services system. This article uses data from seven national demonstration projects funded to enroll persons with HIV/AIDS who tend to "fall through the cracks" and help them access needed services. Data on the initial perceptions of the participants about barriers to accessing services were related to 17 indicators of traditionally underserved status including demographic characteristics and behavioral variables using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). Through the modeling methods, the groups most likely to experience a large number of barriers to service participation are identified. Having children needing care is particularly predictive of the level of barriers to care.

Unmet needs in groups of traditionally underserved individuals with HIV/AIDS: empirical models.

Over the course of the HIV epidemic, the demographics of the populations of affected individuals have changed. Groups that traditionally have been underserved in systems of care have a number of unmet service needs. This article presents results based on data from 478 patients in five national demonstration projects which were funded to enroll individuals from traditionally underserved groups and to help them access services using different strategies. The participants in these programs had a high level of unmet need prior to enrolling in care. Data on client service needs were related to 17 indicators of traditionally underserved status including demographic characteristics and risk behaviors, using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). Crack cocaine users with HIV/AIDS were more likely than other patient groups to have unmet service needs. Patients who were homeless or in precarious housing also were vulnerable. Results are discussed in terms of designing and evaluating innovative service models to close these service gaps.

Finding the underserved: directions for HIV care in the future.

The demographic, behavior, and background characteristics of 4,804 participants in 17 national demonstration projects for HIV medical and/or psychosocial support services were coded for an index of "service need" or possible under-representation in the traditional healthcare system. Fifteen items were coded including status as a person of color, lack of private insurance, unemployment/disability, problem drinking, crack cocaine use, heroin use, other illicit drug use, less than 12 years of education, criminal justice system involvement, children requiring care while the patient receives services, sex work, being the sex partner of an injection drug user, unstable housing, primary language not English, and age less than 21 or over 55 years. Most (87.7%) of the program participants had four or more of these factors present. Through CHAID modeling, those groups with the highest levels of service need and vulnerability were identified. These data suggest that these projects, designed to attract and serve individuals potentially underrepresented in the health services system, had in fact achieved that goal. Implications of the changing demographics of the HIV epidemic for the health service delivery system are discussed.

Satisfaction with innovative community and university health clinic programs for groups of traditionally underserved individuals with HIV/AIDS: empirical models.

As the demographics of the populations of affected individuals have changed, systems of care have needed to adapt to be responsive to client needs. This article examines client satisfaction data from seven national demonstration projects funded to enroll individuals from traditionally underserved groups and help them access services using different strategies. Data on client satisfaction ratings were related to indicators of traditionally underserved status, including demographic characteristics, behaviors, and other risk factors using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). Client groups that were most likely to experience relatively higher and lower levels of satisfaction with services are identified. Overall, all client groups were highly satisfied with the innovative HIV/AIDS services received. The findings illustrate the success of these innovative HIV care models in being responsive and sensitive to the needs of their target populations.

Change in perceived barriers and facilitators to treatment among women with HIV/AIDS as a function of psychosocial service utilization.

Using a repeated assessment of 185 women with HIV in three national service demonstration projects that focus on reducing barriers to care, self-reported barriers to obtaining services decreased significantly over time. At the earliest time asked, participants scored an average of 5.23 on a measure of barriers to obtaining care. At the most recent time asked, they scored an average of 4.05 on the barrier measure. In a subsample of 122 women with HIV, it was found that self-reported facilitators to obtaining services increased significantly over time. At the first time asked, participants scored an average of 8.40 on a measure of facilitators to receiving services. At the most recent time asked, they scored an average of 8.98 on the facilitator measure. Results are discussed in terms of implications for designing services to minimize barriers and maximize facilitators to care for people living with HIV/AIDS.

Women's steps of change and entry into drug abuse treatment. A multidimensional stages of change model.

The Transtheoretical, or Stages of Change Model, has been applied to the investigation of help-seeking related to a number of addictive behaviors. Overall, the model has shown to be very important in understanding the process of help-seeking. However, substance abuse rarely exists in isolation from other health, mental health, and social problems. The present work extends the original Stages of Change Model by proposing "Steps of Change" as they relate to entry into substance abuse treatment programs for women. Readiness to make life changes in four domains-domestic violence, HIV sexual risk behavior, substance abuse, and mental health-is examined in relation to entry into four substance abuse treatment modalities (12-step, detoxification, outpatient, and residential). The Steps of Change Model hypothesizes that help-seeking behavior of substance-abusing women may reflect a hierarchy of readiness based on the immediacy, or time urgency, of their treatment issues. For example, women in battering relationships may be ready to make changes to reduce their exposure to violence before admitting readiness to seek substance abuse treatment. The Steps of Change Model was examined in a sample of 451 women contacted through a substance abuse treatment-readiness program in Los Angeles, California. A series of logistic regression analyses predict entry into four separate treatment modalities that vary. Results suggest a multidimensional Stages of Change Model that may extend to other populations and to other types of help-seeking behaviors.

Typology of quality of life experiences among persons living with HIV.

This article develops a typology of 2,038 participants in 13 innovative HIV/AIDS treatment model service demonstration projects targeted to traditionally underserved populations. The typology is based on self-reported health-related quality of life levels. Eight clusters were identified that classify HIV/AIDS patients based on their reported health-related quality of life. Participants were clustered based on their overall levels of quality of life, as well as by deficits in specific areas of functioning such as energy level, physical impairment, and role impairment. However, factor analysis suggests that health-related quality of life as perceived by the HIV-positive participants is best represented as a single underlying dimension and an ordering of the types shows that they are consistently related, in the same order, to several criterion measures of impairment. The results suggest that a general categorization of patients with HIV in terms of quality of life is more meaningful than an assessment of the relative areas of impairment. Since the impairment ratings were also self-reported, analyses relating quality of life clusters to actual symptom levels and healthcare utilization are needed. Implications for the assessment of health-related quality of life and the evaluation of service delivery programs for persons living with HIV are discussed.

Service needs and factors related to quality of life at time of service enrollment among persons living with HIV.

This article explores the relationships of HIV risk factors, service needs, and vulnerabilities to health-related quality of life in a sample of 1,371 participants newly enrolled into 13 innovative HIV/AIDS treatment model service demonstration projects. These projects targeted services to traditionally underserved populations. Eight distinct quality of life clusters of HIV patients were used in this analysis along with patient self-identified risk factors. The quality of life clusters were based on patient self-reported quality of life dimensions. The eight clusters were differentiated based on relative strengths and weaknesses in physical functioning, energy levels, and social functioning. Data on patient need-vulnerability factors and demographic characteristics were related to these eight clusters using the data modeling method of Exhaustive CHAID (Chi-squared Automatic Interaction Detector). Through this method, the characteristics most likely to be associated with higher and lower levels of quality of life at the time of enrollment into services were identified. The results provide further support that quality of life assessment is a useful clinical tool for monitoring patient progress.

Level of burden among women diagnosed with severe mental illness and substance abuse.

Women diagnosed with severe mental illness and substance abuse may face a variety of associated difficulties that require intervention, including other health-related problems, housing instability or homelessness, and a history of or current physical or sexual abuse. This article expands upon the concept of "level of burden" by specifically examining issues for women with multiple vulnerabilities in a sample of 577 women participating in a residential substance abuse treatment program. Two types of outcomes were examined for the women. In Study 1, the effects of severe mental illness as well as overall level of burden on retention in treatment were examined. Cox regression analyses revealed that severe mental illness was significantly related negatively to retention in treatment; those women diagnosed with severe mental illness tended to stay in treatment less time than those without such a diagnosis. In Study 2, staff ratings of the women's status at departure from residential treatment for a subsample of 311 women were examined with respect to overall retention in treatment and severe mental illness. Ratings of client status at program exit were significantly related to time in program but were not related to having a severe mental illness diagnosis. For a few indicators (e.g., leaving treatment against advice, having scattered or disorganized thoughts, and having no specific plans for life outside of treatment), there was an interaction between time in program and severe mental illness such that women with severe mental illness who were retained for less than 180 days were more likely to demonstrate negative outcomes. Implications for the treatment of multiply-diagnosed women are discussed.

Evaluation of the effects of outreach to women with multiple vulnerabilities on entry into substance abuse treatment.

This paper examines ways in which the level of participation in intensive outreach contributes to entry into substance abuse treatment. It was hypothesized that the number of outreach contacts to substance abusing women predicts the likelihood of their entry into drug abuse treatment. As such women often have multiple vulnerabilities that impact upon their needs and readiness for seeking treatment, we also examine the relationships among readiness to seek assistance, the women's level of involvement with the outreach project, and admission to treatment. A sample of 665 women who participated in an enhanced outreach and treatment readiness preparation program was tracked to examine patterns of referral and entry into substance abuse treatment. The number of outreach contacts was inversely related to receiving referrals to substance abuse treatment, as well as to the completion of those referrals (for a subsample of 551 women who had received referrals). In addition, victims of domestic violence were 50% more likely to receive a referral to drug abuse treatment, but of the women who received such a referral, the lack of involvement in a violent relationship predicted entry into treatment. Findings are discussed in terms of their implications for designing and implementing outreach and treatment programs for women with multiple therapeutic issues, particularly substance abuse and domestic violence.

Challenges in moving from a traditional therapeutic community to a women and children's TC model.

With the advent of specialized programs for addicted women and their children, some of the traditional methods used by therapeutic communities have been undergoing significant changes. This article examines the issues that are important for treatment providers to consider as they move from individual client and community orientation to a mother-child/family-centered and community approach. The major adaptations suggested are divided into three categories: structural design issues, including living arrangements and models of childcare; treatment issues, including acting-out behavior by the children; and staff and training issues, including staff composition.

Level of burden: women with more than one co-occurring disorder.

Utilizing an expanded concept of level of burden, the impact of multiple problems experienced by women in a residential drug abuse treatment program on treatment retention and outcomes is investigated. Level of burden is defined in this study as the number and severity of problems, including psychological problems, cognitive impairment, chronic health problems, HIV/AIDS status, as well as substance abuse. In the first study of 260 women, the ability to retain women in treatment as a function of their level of burden is examined using the technique of survival analysis. Results indicate that early in the course of treatment, high-burden clients tend to be the highest risks for early termination. In addition, there is a significant interaction between time in the program and level of burden. In the second study of 68 women, partial correlations between level of burden and ratings of outcomes by program staff at time of discharge are examined. Results show that many of the treatment outcomes are significantly negatively correlated with the initial levels of burden. Implications for treatment providers and directives for future studies are discussed.

Psychological functioning and substance abuse before and after the 1992 Los Angeles riot in a community sample of women.

An ongoing study of interventions designed to increase nontraditional social supports among women at high risk for HIV infection was in the field during the 1992 Los Angeles riot in those neighborhoods most affected by the urban unrest. Using data from structured interviews, the psychosocial characteristics, drug abuse patterns, and distress levels among the women who were recruited for the project in the six months before and after the riot were examined. While substance abuse levels among participants did not increase or decrease as a function of the riot, there were a smaller number of social supports and marginally greater levels of already high psychological distress. Women in the community specifically mentioned a lack of social supports from counselors available in affected areas after the riot. An ethnographic analysis discusses the experience of the participants in the community during the same period of time. Problems in social supports are pointed out. The results are discussed in terms of a general theory of service provision by increasing nontraditional social supports, especially immediately after a major cataclysm.

Immunohistochemical and histochemical properties of surgically excised subretinal neovascular membranes in age-related macular degeneration.

The immunohistochemical and histochemical properties of 16 surgically excised subretinal neovascular membranes from 16 patients with age-related macular degeneration were studied. Primary antisera to c-retinaldehyde-binding protein; leukocyte common antigen; factor VIII-related antigen; S-100 protein; glial fibrillary acid protein; muscle-specific actin; neuron-specific enolase; collagen types I, II, III, IV, and V; laminin; and fibronectin were used for immunohistochemical characterization of the membranes. Histochemical staining for lipid and mucopolysaccharide was performed. The results of the staining in conjunction with histologic examination showed the cellular components of the membranes to be composed of retinal pigment epithelium, inflammatory cells, vascular endothelium, glial cells, myofibroblasts, photoreceptor cells, and fibrocytes. The extracellular matrix of the membranes contained collagen types I, III, IV, and V; fibronectin; laminin; mucopolysaccharide; and lipid. These findings are consistent with the concept that subretinal neovascular membranes in age-related macular degeneration are composed of localized intra-Bruch's membrane granulation tissue proliferation associated with diffuse drusen.