Qualitative study of barriers and facilitators of health entrepreneurship in rural and semirural communities of Armenia.

INTRODUCTION: Low- and middle-income countries often face the issue of unequal distribution of healthcare services and human resources between rural and urban areas. Globally, there are many factors negatively affecting the willingness of physicians to work in remote and rural areas, such as low wages, poor living conditions, poorer and sicker patients, suboptimal equipment and supplies, and a lack of quality infrastructure and transportation. METHODS: This study explored the perceptions of barriers and facilitators of medical entrepreneurship and the impact of medical entrepreneurship on the served communities among the owners of private medical practices in rural and semirural areas of Armenia. The researchers conducted qualitative in-depth interviews with the 13 owners of 12 private practices. The interviews were transcribed in the original language (Armenian). Only the quotes were translated into English. The direct content analysis approach was used for analyzing textual data. RESULTS: The findings of the study suggest that high investment cost, intense competition with state facilities, unfavorable laws and regulations, and a lack of entrepreneurship and healthcare quality assurance skills were perceived as barriers to establishing and running private healthcare practices. The dissatisfaction of healthcare providers with their work conditions in state facilities, the instability of the job market in Armenia, and the development of clear marketing strategies by the entrepreneurs facilitated opening and operating private practices. All of the interviewees felt that their practices had a positive impact on the communities they served, in terms of creating new jobs and introducing up-to-date and in-demand services into these communities. CONCLUSION: The study recommended providing potential entrepreneurs with training in entrepreneurship and healthcare quality assurance and mentorship opportunities, as well as with tools to support financing their enterprises.

Male labor migration, patriarchy, and the awareness-behavior gap: HIV risks and prevention among migrants' wives in Armenia.

Unlike in most of the world, HIV incidence in the former Soviet Union continues to rise. While international labor migration has been identified as a potentially important contributor to this trend, most attention has been focused on risks of male migrants themselves. This study uses recent household survey data to examine HIV-related perceptions and actions of migrants' left-behind wives in Armenia. Multivariate logistic regression analyses show that migrants' wives are significantly more likely to suspect their husbands of extramarital sex than are non-migrants' wives. The analyses detect greater worries about HIV infection and a higher likelihood of spousal communication on HIV matters among migrants' wives, compared to non-migrants' wives, but these differences are largely explained by the suspicion of husband's extramarital sex. Finally, no difference between the two categories of women in the probability of consistent condom use with husbands is found. These findings are interpreted within the context of patriarchal culture and unequal gender relations in Armenian society as they are further reinforced by male migration. Implications of these findings for policies to increase women's awareness of HIV risks associated with migration and their ability to reduce those risks are discussed.

Correlates of Inconsistent Refusal of Unprotected Sex among Armenian Female Sex Workers.

This cross-sectional study assessed the prevalence and correlates of inconsistent refusal of unprotected sex among female sex workers (FSWs) in Armenia. One hundred and eighteen street-based FSWs between the ages of 20 and 52 completed a questionnaire assessing FSWs' demographic, psychosocial, and behavioral characteristics. A total of 52.5% (n = 62) of FSWs reported inconsistent refusal of unprotected sex with clients in the past 3 months. Logistic regression analysis controlling for participants' age and education revealed that perceiving more barriers toward condom use (AOR = 1.1; P < 0.01), reporting more types of abuse (AOR = 2.1; P < 0.01), and setting lower fees for service (AOR = 0.9; P = 0.02) significantly predicted inconsistent refusal of unprotected sex. HIV-risk-reduction behavioral interventions tailored to FSWs working in Yerevan Armenia should address the factors identified in this study toward the goal of enhancing refusal of unprotected sex and ultimately preventing acquisition of sexually transmitted infections (STIs) including HIV.

Gender based violence as a risk factor for HIV-associated risk behaviors among female sex workers in Armenia.

This cross-sectional study identified the prevalence of gender based violence (GBV) and examined its association with sexual risk behavior among female sex workers (FSWs). Among 120 participants between ages 20 and 52, a total of 56.7 % reported lifetime GBV. Multivariate analyses revealed that GBV was significantly associated with inconsistent condom use, unprotected sex, condom misuse, fear of client reaction to requests of condom use, self-reported history of STIs, and earlier age of initiation of sex work. GBV must be considered an urgent public health priority among FSWs in Armenia. Interventions addressing FSWs, in addition to targeting skill-based, sexual risk reduction must also introduce a discourse among FSWs, sexual partners, clients and community members about the role of GBV in HIV-associated risk behaviors and infection. Structural level initiatives must address economic opportunities for women, health-sector policies and responses to FSWs' health needs, law enforcement training and societal norms toward women.

Application of condoms on male clients by female sex workers in Yerevan, Armenia: prevalence and correlates.

This study sought to assess the prevalence of consistent condom application on male clients by female sex workers (FSWs) in Armenia and its association with demographic, psychosocial and behavioural factors. In this cross-sectional study, 120 street-based FSWs aged 20-52 completed an interviewer-administered questionnaire. The primary outcome measure was consistent application of condoms by FSWs on their male clients. A total of 21.7% of participants reported consistently applying condoms on clients. Logistic regression analysis demonstrated that higher condom use self-efficacy (Adjusted Odds Ratio, AOR=1.1; p=0.01), lower perceived condom use barriers (AOR=0.9; p=0.04) and not using douching as a method to prevent STI/HIV (AOR=4.8; p=0.04) significantly predicted consistent condom application. Higher HIV/AIDS knowledge was a marginally significant predictor of condom application (AOR=1.3; p=0.05). Future interventions should address these modifiable factors to encourage FSWs to apply condoms on clients themselves, which may reduce condom failure and exposure to HIV transmission.

A randomized controlled trial of an HIV prevention intervention for street-based female sex workers in Yerevan, Armenia: preliminary evidence of efficacy.

This study evaluated the efficacy of an HIV intervention among female sex workers (FSWs) randomized to an intervention or wait-list control. FSWs (N = 120) completed baseline, 3- and 6-month assessments. A health educator implemented 2-hour intervention emphasized gender-empowerment, self-efficacy to persuade clients to use condoms, condom application skills, and eroticizing safer sex. Over the 6-month follow-up, FSWs in the intervention reported more consistent condom use with clients (P = .004) and were more likely to apply condoms on clients (P = .0001). Intervention effects were observed for other psychosocial mediators of safer sex. Brief, gender and culturally congruent interventions can enhance HIV-preventive behaviors among FSWs.

Effect of antihypertensive medication adherence among employees with hypertension.

OBJECTIVES: To determine if antihypertensive medication adherence is associated with decreased medical and drug costs, medical service utilization, and work absence days. STUDY DESIGN: Retrospective database study using medical, pharmacy, sick leave, short-term and long-term disability, and workers' compensation claims data from multiple large US employers from 2001 to 2008. METHODS: We used medical and pharmacy claims to identify employees with hypertension. The index date was the date of the first hypertension-related pharmacy claim. Eligible employees had health plan enrollment 6 months before the index date and at least 12 months after the index date. Employees younger than 45 years were excluded from the study. Regression models estimated the effect of the proportion of days covered (PDC) by hypertension medication on outcomes after the index date, including health benefit costs, medical service utilization, and work absence days, as well as some clinical outcomes calculated separately for high-prior-cost and low-prior-cost employees. High-prior-cost employees were those who accounted for the top 60.0% of total medical costs during the 6 months before the index date. The regression models controlled for demographics, job-related variables, and comorbidities. RESULTS: Among low-prior-cost employees, high PDC was associated with increased medical and drug costs and work absence days. Among high-prior-cost employees, high PDC was associated with decreased medical and drug costs, fewer work absence days and inpatient hospital days, and increased hypertension-specific medical costs. CONCLUSION: Antihypertensive medication adherence was associated with improvement in some short-term utilization measures among high-prior-cost employees, but significant short-term improvement was not seen among low-prior-cost employees.

Incremental employee health benefit costs, absence days, and turnover among employees with ADHD and among employees with children with ADHD.

OBJECTIVE: To assess employer economic burden of attention-deficit/hyperactivity disorder (ADHD) for employees with ADHD and employee caregivers of children with ADHD. METHODS: A large multi-employer database was used to compare: 1) employees diagnosed with ADHD versus employees without ADHD and 2) employee caregivers of children with ADHD versus employee caregivers of children without ADHD. Regression modeling compared many employer-relevant outcomes. RESULTS: The study found significantly higher annual health benefit costs ($6885 versus $4242), absence days (8.86 versus 7.16), and turnover (8.99% versus 5.26%) for employees with ADHD (n = 539) versus employees without ADHD (n = 93,722), respectively (all P < 0.01). Similar results were found for employee caregivers of children with ADHD. CONCLUSIONS: Employees with ADHD and those caring for children with ADHD are associated with a significantly higher burden in employer-relevant outcomes such as health benefit costs, absences, and terminations.

Correlates of HIV risk and preventive behaviors in Armenian female sex workers.

This study describes HIV risk and preventive behaviors and their correlates among Armenian female commercial sex workers (CSWs) as a prerequisite to developing gender and culturally appropriate interventions. Ninety-eight CSWs from three Armenian cities were interviewed using a structured questionnaire. Quantitative findings were further elaborated by focus group discussions (N = 25) and key informant interviews (N = 8). Inconsistent condom use with all types of sexual partners was reported, as were condom tear/slippage, alcohol and drug use, and sex with drug injecting clients. Prominent misconceptions regarding HIV transmission, prevention and disease manifestations were noted. Correlates of condom use intentions included history of substance use, attitudes regarding condom use, risk perception, and comfort negotiating condom use. Intentions to use condoms were strongly associated with recent frequency of condom use. Understanding the relationship between condom use and its determinants is critical in the design and implementation of effective prevention programs tailored for Armenian CSWs.

Meeting the challenge of injection drug use and HIV in Armenia.

This article is based on research on the response to drug use and HIV in Armenia and its conflicts with international law. It was conducted via an assessment of legal documents, resolutions, and position papers on drugs, human rights, and HIV, and an analysis of their practical exercise in Armenia. The article provides an overview of challenges to effective responses to drug use and HIV in Armenia, outlines the rationale for adopting human rights-based approaches, provides justification that the latter approaches would allow Armenia to better comply with its obligations under international treaties, and proposes policy recommendations for the promotion of human rights-based approaches.