The effects of a problem solving-based intervention on depressive symptoms and HIV medication adherence are independent.

Depression and depressive symptoms predict poor adherence to medical therapy, but the association is complex, nonspecific, and difficult to interpret. Understanding this association may help to identify the mechanism explaining the results of interventions that improve both medical therapy adherence and depressive symptoms as well as determine the importance of targeting depression in adherence interventions. We previously demonstrated that Managed Problem Solving (MAPS) focused on HIV medication adherence improved adherence and viral load in patients initiating a new antiretroviral regimen. Here, we assessed whether MAPS improved depressive symptoms and in turn, whether changes in depressive symptoms mediated changes in adherence and treatment outcomes. We compared MAPS to usual care with respect to presence of depressive symptoms during the trial using logistic regression. We then assessed whether MAPS' effect on depressive symptoms mediated the relationship between MAPS and adherence and virologic outcomes using linear and logistic regression, respectively. Mediation was defined by the disappearance of the mathematical association between MAPS and the outcomes when the proposed mediator was included in regression models. Although MAPS participants had a lower rate of depressive symptoms (OR = 0.45, 95% confidence interval 0.21-0.93), there was no evidence of mediation of the effects of MAPS on adherence and virological outcome by improvements in depression. Thus, interventions for medication adherence may not need to address depressive symptoms in order to impact both adherence and depression; this remains to be confirmed, however, in other data.

Managed problem solving for antiretroviral therapy adherence: a randomized trial.

BACKGROUND: Adherence to antiretroviral therapy is critical to successful treatment of human immunodeficiency virus (HIV). Few interventions have been demonstrated to improve both adherence and virologic outcomes. We sought to determine whether an intervention derived from problem solving theory, Managed Problem Solving (MAPS), would improve antiretroviral outcomes. METHODS: We conducted a randomized investigator blind trial of MAPS compared with usual care in HIV-1 infected individuals at 3 HIV clinics in Philadelphia, Pennsylvania. Eligible patients had plasma HIV-1 viral loads greater than 1000 copies/mL and were initiating or changing therapy. Managed Problem Solving consists of 4 in-person and 12 telephone-based meetings with a trained interventionist, then monthly follow-up calls for a year. Primary outcome was medication adherence measured using electronic monitors, summarized as fraction of doses taken quarterly over 1 year. Secondary outcome was undetectable HIV viral load over 1 year. We assessed 218 for eligibility, with 190 eligible and 180 enrolled, 91 randomized to MAPS and 89 to usual care. Fifty-six participants were lost to follow-up: 33 in the MAPS group and 23 in usual care group. RESULTS: In primary intention-to-treat analyses, the odds of being in a higher adherence category was 1.78 (95% CI,1.07-2.96) times greater for MAPS than usual care. In secondary analyses, the odds of an undetectable viral load was 1.48 (95% CI, 0.94-2.31) times greater for MAPS than usual care. In as-treated analyses, the effect of MAPS was stronger for both outcomes. There was neither a difference by prior treatment status nor change in effect over time. CONCLUSIONS: Managed Problem Solving is an effective antiretroviral adherence intervention over the first year with a new regimen. It was equally effective at improving adherence in treatment experienced and naïve patients and did not lose effect over time. Implementation of MAPS should be strongly considered where resources are available. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00130273.

The relationship of body size to participation and success in a fruits and vegetables intervention among low-income women.

We examined participation and dietary change among women participants in a community-based nutrition education program, to determine whether intervention results differed by participant body size. Four dietary indicators (daily servings of fruits and vegetables, total calories, calories from fat, and Healthy Eating Index score) were assessed from 24-h recalls taken before, immediately after, and 4 months after a seven-session nutritional education program, from 156 African-American women age 20-50, in Washington, D.C. public housing. Knowledge, attitudes and practices related to nutritional behavior change were collected at three time points as well. Random effect models were used to examine dietary patterns, and compare change by body size and class attendance. Results showed that obese women (BMI > or = 30) had more psychosocial barriers to dietary change and poorer baseline diets, but stronger program attendance. Post-intervention, both groups consumed approximately 250 fewer calories and 2.5% fewer calories from fat. At follow-up, non-obese women consumed significantly fewer calories; obese women consumed significantly fewer calories from fat, and showed significant improvement in HEI. Given the prevalence of obesity in low resource communities, nutritional interventions should tailor strategies to participant body size and related psychosocial needs.

Evaluation of a nutrition education intervention for women residents of Washington, DC, public housing communities.

We designed, implemented and evaluated an educational intervention to increase fruit and vegetable consumption among urban African-American women. Women aged 20-50 years (n=212) from 11 public housing communities participated in seven 90-min classes with a professional nutritionist. Our prospective pre- and post-test design, with 4-month follow-up, assessed the relationship between attendance and dietary change, using three 24-hour recalls per time point. Mean change in average daily dietary values for fruits and vegetables, calories and percent calories from fat (post-test versus pre-test, follow-up versus pre-test) was compared by class attendance, to evaluate the impact of class attendance on dietary change. Attendance varied from zero (35%) to five to seven classes (42%). Baseline dietary recalls showed average daily consumption of 3.05 servings of fruits and vegetables, 2416 calories and 35.8% calories from fat. No improvements in fruit and vegetable consumption, but statistically significant decreases in total calories and percent calories from fat, were seen at both endpoints. Women attending five to seven classes had the greatest dietary improvements, averaging, at post-test and follow-up, respectively, 246.2 and 324.5 fewer calories and 3.08 and 2.97% fewer calories from fat. Results suggest that, for some residents of low-resource communities, small group interventions are popular, effective vehicles for nutrition education.

The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence.

OBJECTIVE: To assess the effects of pictures on health communications. METHOD: Peer reviewed studies in health education, psychology, education, and marketing journals were reviewed. There was no limit placed on the time periods searched. RESULTS: Pictures closely linked to written or spoken text can, when compared to text alone, markedly increase attention to and recall of health education information. Pictures can also improve comprehension when they show relationships among ideas or when they show spatial relationships. Pictures can change adherence to health instructions, but emotional response to pictures affects whether they increase or decrease target behaviors. All patients can benefit, but patients with low literacy skills are especially likely to benefit. Patients with very low literacy skills can be helped by spoken directions plus pictures to take home as reminders or by pictures plus very simply worded captions. PRACTICE IMPLICATIONS: Educators should: (1) ask "how can I use pictures to support key points?", (2) minimize distracting details in pictures, (3) use simple language in conjunction with pictures, (4) closely link pictures to text and/or captions, (5) include people from the intended audience in designing pictures, (6) have health professionals plan the pictures, not artists, and (7) evaluate pictures' effects by comparing response to materials with and without pictures.

Project Genesis: assessing the efficacy of problem-solving therapy for distressed adult cancer patients.

The efficacy of problem-solving therapy (PST) to reduce psychological distress was assessed among a sample of 132 adult cancer patients. A second condition provided PST for both the patient and a significant other. At posttreatment, all participants receiving PST fared significantly better than waiting list control patients. Further, improvements in problem solving were found to correlate significantly with improvements in psychological distress and overall quality of life. No differences in symptom reduction were identified between the 2 treatment protocols. At a 6-month follow-up, however, patients who received PST along with their significant other reported lower levels of psychological distress as compared with members of the PST-alone condition on approximately half of the outcome measures. These effects were further maintained 1-year posttreatment.

Viatical settlements: effects on terminally ill patients.

PURPOSE: This study was performed to assess the knowledge, attitudes, and experiences with viatical settlements among hospice staff who provide financial counseling to terminally ill patients and their families. DESCRIPTION OF STUDY: A random sample of 300 hospices in the 50 states was selected from the National Hospice Directory. Staff members who provide financial counseling to patients and families were interviewed by phone using a 31-item structured questionnaire. RESULTS: The response rate was 80%. The results showed that only 4% of hospices provide information about viatical settlements to all patients, while 32% provide information only if asked. Only 9% of respondents rated themselves as very informed about viatical settlements, and 53% rated themselves as moderately informed. Of the 47 hospices where at least one patient had used a viatical settlement, 92% felt the patient had a positive experience using the resource. In response to a hypothetical case of a terminally ill patient considering a viatical settlement, 40% responded positively, while 51% were neutral. CLINICAL IMPLICATIONS: Among hospice financial counselors who have had experience with viatical settlements, most report positive experiences. When asked to respond to a hypothetical case, most respondents were either neutral or positive. However, lack of knowledge about viatical settlements may limit the availability of this resource for terminally ill patients and their families.

The psychological impact of the Three Mile Island incident

This study examines the psychological impact of the Three Mile Island incident. The results are based on data from a panel study of 403 persons living within Five Miles of Three Mile Island (TMI), and a telephone survey of 1,506 people living within 55 miles of that area. Active coping strategies were associated with continued high levels of distress. Having more friends was related to reduced distress, but introspection, taking protective actions, being active in organizations, and seeking out others were all related to higher levels of distress. High self-esteem was related to a decrease in symptoms and psychotropic drug use, and avoidance behaviors were related to higher than expected numbers of symptoms. Efforts to profile those who used different coping strategies were relatively unsuccessful. The results emphasize the need to consider the nature of the stressor when developing models of coping and response to stressful situations (AU)

The near disaster at three Mile Island

On March 28, 1979, a serious reactor accident accurred at the Three Mile Island nuclear power plant near Harrisburg, Pennsylvania (USA). Pregnant women and families with pre-school age children were asked to evacuate a five mile area around the plant.Evacuation plans were development for a twenty miles radius, although no such evacuation occurred. Telephone surveys of adults and a questionnaire survey of high school students living near Three Mile Island were carried out from May , 1979, to January, 1980. The data collect show that liveng near the plant (absolute or perceived proximity), younger age and lower grade level of the adolescent respondet, presence of pre-school age child in the homw, lower parent's or adult's education, and evacuation of all or part of the family were all associated with a stronger negative effective response to the accident and with the likelihood of having evacuated the area. The behavior of individuals and families following the Three Mile Island accident parallel those occuring in an actual disaster, and extend the theorical framework of Kinston and rosser to include the circumstances of potential disasters (AU)