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.

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.

Nurses decrease barriers to health care by "hyperlinking" multiple-diagnosed women living with HIV/AIDS into care.

The Well-Being Institute (WBI), a community-based nursing organization in Detroit, Michigan, has developed and put into practice innovative intervention and service delivery models to assist HIV-positive women who have a history of substance abuse and mental illness. These multiple-diagnosed women are known to have special problems and barriers to accessing health care. The service delivery model is based on "hyperlinking" women into hard-to-get health care appointment slots through nurses' personal contacts in health care clinics. The intervention model is the personalized nursing LIGHT model. This article describes the service delivery and intervention models and discusses outcomes of the WBI Women's Intervention Program in practice. The program locates HIV-positive, substance-abusing women; enrolls them in primary medical and mental health care; and helps retain them in health care. The results of the model in practice demonstrate its success in hyperlinking hard-to-reach and hard-to-serve HIV-positive women with health care and other needed services and resources. In addition, these multiple-diagnosed women have shown positive effects with respect to improved sense of well-being and decreased psychosocial distress.

Prevalence of HIV infection and HIV risk behaviors associated with living place: on-the-street homeless drug users as a special target population for public health intervention.

The study described here examined the prevalence of HIV infection as a function of place of residence and high-risk behaviors in six subpopulations of out-of-treatment drug injectors and crack cocaine users who participated in the National Institute on Drug Abuse (NIDA) Cooperative Agreement project. The subpopulations were blacks, Hispanics, and non-Hispanic whites sampled separately by gender. The research asked three questions: (a) Is the HIV infection rate higher among the on-the-street homeless than among those in other places of residence? (b) Do high-risk drug-related behaviors differ by housing status? and (c) What are the joint effects of high-risk drug-related behaviors and housing status on the probability of HIV infection? Overall, on-the-street homeless had a significantly higher HIV+ rate (19.0%) than the study population as a whole (11.2%). Rates differed by gender and race, with exceptionally high HIV+ rates for on-the-street homeless Hispanic males (29%) and females (32%) and for on-the-street homeless black females (38%). Having used drug works previously used by a HIV-infected person was a strong predictor of HIV+ status, as was frequency of drug injections and crack use. Having multiple sex partners was also a significant risk behavior. Findings argue against considering on-the-street homelessness as equivalent to shelter dwelling or aggregated homelessness for purposes of the AIDS epidemic. On-the-street homeless drug users were at strong risk for acquisition and transmission of HIV infection and therefore in need of targeted-racially relevant, ethnically relevant, and gender-relevant-public health interventions to help prevent the spread of AIDS.

Women living with drug abuse and HIV disease: drug abuse treatment access and secondary prevention issues.

In collaboration with the National Institute on Drug Abuse, the Health Resources and Services Administration is conducting a multisite, longitudinal study on issues of service needs, service utilization, and access to care for drug abusers with HIV. This article discusses access to drug abuse treatment and HIV secondary prevention for 116 women interviewed during the study's first year in five U.S. cities. Using interview data from 115 service providers in those same cities, it also discusses drug abuse treatment availability and barriers to service expansion for drug users with HIV. Study findings indicate that there are highly significant gaps between the drug abuse treatment services these women feel they need and those they have been able to receive; these were particularly pronounced for drug detoxification and residential and outpatient drug-free treatment. Women who used crack cocaine or injection drugs had particularly high levels of need for residential and outpatient drug abuse treatment, while women who use crack were found to have significantly less experience with the drug abuse treatment system than IDUs. HIV secondary prevention was also found to be a critical need for these women, many of whom were engaging in behaviors that place them at risk for reinfection, infection with other diseases, and transmission to others. Providers indicated that lack of funding was the major barrier to expanding services for this population; other barriers, such as lack of ancillary services and transportation, were also noted. Two positive findings were that many drug abuse treatment agencies in these cities provide a wide range of ancillary services and that many different kinds of agencies offer drug abuse treatment services.

LIGHT model: an effective intervention model to change high-risk AIDS behaviors among hard-to-reach urban drug users.

Two thousand thirty-three hospital emergency room (ER) patients who were current, active injecting drug users (IDUs) were voluntary participants in a pretest, posttest research project which utilized a nursing model, the Personalized Nursing LIGHT Model, as a counseling approach to decrease high-risk AIDS behaviors. The LIGHT Model works by directly improving well-being and thereby indirectly decreasing high-risk behaviors associated with AIDS. Addicts from an urban ER in each of three cities (Detroit, Michigan; Brooklyn, New York; and Baltimore, Maryland) were treated with teams consisting of nurses and indigenous outreach workers. Posttest data were gathered on 995 of the clients who received the Personalized Nursing LIGHT Model teaching and counseling intervention. In a posttest at least 3 months after the initial interview, these IDUs reported a significant increase in well-being, t(530) = -11.77; p < .001, and significant reductions in frequency of IV heroin use, z = -18.4; p < .001, IV cocaine use, z = -16.0; p < .001, and IV speedball use, z = -14.3; p < .001, as well as significant decreases in sharing of cookers (a type of drug-using equipment), z = -13.8; p < .001, and other high-risk behaviors associated with AIDS acquisition and transmission. At a second posttest, at least 6 months after the initial interview, these results were unchanged.

The consciousness rainbow: an explication of Rogerian field pattern manifestations.

The consciousness rainbow is a heuristic designed to be used in nursing practice in conjunction with the personalized nursing practice model based on Rogers' science of unitary human beings (Rogers, 1970, 1990). The first phase in practicing nursing is pattern manifestation appraisal, followed by deliberative mutual patterning. This article presents pattern manifestation appraisal by describing patterns associated with "being," "well-being," and "not being." Clients who enter well-being via another dimension are encouraged to experience "being" in the present as a step toward genuine well-being.

Personalized nursing LIGHT model. Love, Intend, Give, Help, Touching.

The Personalized Nursing LIGHT model is a prescriptive model for nursing. It is a model for nursing practice derived from a synthesis of Aristotle's theory of ethics and Martha E. Rogers' science of unitary human beings. The LIGHT model provides a mechanism for nurses to assist clients to improve their sense of well-being. The authors believe that improving well-being is the focus of nursing. Using principles synthesized from Aristotle and Rogers, clients are encouraged to use their talents in the pursuit of well-being and happiness in an increasingly complex world.