STAND: a peer educator training curriculum for sexual risk reduction in the rural South. Students Together Against Negative Decisions.

BACKGROUND: The incidence of AIDS in rural areas continues to increase rapidly, with teenagers continuing to report high rates of sexual risk behaviors. Unfortunately, there is a dearth of effective HIV prevention programs targeting youth in rural settings where there are often formidable barriers to sex education programs. This paper describes a theoretically based intervention designed to meet the needs of rural youth. METHODS: Students Together Against Negative Decisions (STAND) is a 28-session teen peer educator training program implemented in a rural county in a southeastern state, promoting both abstinence and sexual risk reduction. The theoretical foundation of the curriculum includes both Diffusion of Innovations Theory and the Transtheoretical Model, focusing on both individual and community norm change. STAND is teen-centered and skills-based; activities focus on active learning. Educator trainees are selected on the basis of their opinion leadership within their peer group, resulting in a training group of both virgin and sexually active teens, balanced for gender and matched to the racial proportions of the school. RESULTS: Acceptance and participation in STAND suggest that adolescents in rural communities can be accessed through community-based interventions, that they are willing to participate in such intensive programs, and that they perceive the intervention as valuable and enjoyable. Moreover, the STAND program has thrived in a relatively conservative rural environment, and has had a positive impact on adolescents' sexual risk taking. Results from a pilot study showed significantly greater increases in condom use self-efficacy (16% vs a 1% decrease among controls) and in consistent condom use (+28% vs +15%). Adolescent trainees also reported a sevenfold larger increase in condom use (+213% vs +31%) and a 30% decrease in unprotected intercourse compared to a 29% increase among controls. CONCLUSIONS: STAND represents a new genre of HIV prevention program, one that utilizes complementary theoretical models to develop a program that targets both individual- and community-level change for rural adolescents.

Students together against negative decisions (STAND): evaluation of a school-based sexual risk reduction intervention in the rural south.

Twenty-one 10th graders selected as opinion leaders by their peers in a rural county in a southern state participated in a 36-hour peer-educator training program Students Together Against Negative Decisions (STAND) based on diffusion of innovations theory and the transtheoretical model. Comparison subjects received either a 22-hour leadership training course (n = 20) or no intervention (n = 45). STAND and comparison subjects completed a 154-item written knowledge, attitude, and behavior survey at the beginning of the training (Time 1), at the end of the training (Time 2), and again 8 months later (Time 3). One hundred and sixty-seven other 9th and 10th graders in the intervention county and 74 in the comparison county completed an abbreviated telephone interview at Time 1 and Time 3. At Time 3 STAND-trained peer educators reported significantly greater increases in AIDS Risk Behavior Knowledge (more than 4 times comparison groups), frequency of conversations with peers about birth control/condoms (+180% vs. +12%) and sexually transmitted diseases (STDs; +282% vs. -33%), condom use self efficacy (+16% vs. -1%), and consistent condom use (+28% vs. +15%). STAND teens also reported substantial favorable trends at Time 3, including increased condom use (+213% vs. +31%) and decreased unprotected intercourse (-30% vs. +29%). At Time 3 teens in the intervention county reported significantly greater increases in the number of people who talked with friends in the preceding 3 months about STDs (+39% vs. -19%) or with a parent/adult about sex (+6% vs. -37%). Intervention county teens also reported a substantial but nonsignificant 2.6-fold greater increase in condom use at last intercourse (+64% vs. +25%) but unfavorable changes in other risk behaviors. The STAND peer-educator training program appears to be an effective method for improving selected sexual knowledge, attitudes, and behaviors among participant teenagers in the rural South.

Quasi-experimental evaluation of three AIDS prevention activities for maintaining knowledge, improving attitudes, and changing risk behaviors of high school seniors.

Twelfth graders in a small southern city participated in one of three interventions: a question and answer (QA) session, a presentation by a person with AIDS (PWA), or a role-play activity (RP). A pre-intervention questionnaire assessed AIDS-related knowledge and attitudes. Immediate post-intervention questionnaires assessed knowledge and the intervention itself, and, five weeks later, a questionnaire reassessed knowledge and attitudes in addition to changes in risk behaviors. Knowledge gains were similar in the three groups; forgetting was greatest among PWA students. The attitudes of the RP group toward persons with AIDS tended to be the most positive, but differences among the groups were not statistically significant. The pro- portion of RP students (65.9% ) who reported changing their sexual activities after the intervention was significantly greater than that proportion of the other groups. These findings suggest that role-play activities can be more effective in achieving HIV/AIDS-related attitudinal and behavioral change than question-and-answer discussions or presentations by PWAs.

Arteriographic incidence of coronary artery disease in black men with chest pain.

To determine the incidence of arteriographically proven coronary artery disease in black men evaluated for chest pain, we retrospectively reviewed the charts of 208 black men, aged 20 to 60, who had coronary arteriography at the Medical Center of Central Georgia (MCCG) from 1985 through January 1990. Age, type of chest pain, and risk factors commonly accepted as associated with coronary disease (hypertension, family history, left ventricular hypertrophy, diabetes, smoking, and hypercholesterolemia) were identified for each patient. Patients were categorized by previous evidence of coronary disease: 145 were studied to evaluate suspected disease and 63 to evaluate previously proven (prior catheterization) or presumptive (prior myocardial infarction) disease. Chest pain groups (typical and atypical angina) were analyzed by Pearson chi-square goodness of fit using the Diamond and Forrester age and chest pain tables as a model. Risk factors were analyzed using a maximum likelihood chi-square test. Coronary artery disease was common in the study group (48.6% of all patients) but significantly less than predicted by the Diamond and Forrester tables. Risk factors were highly prevalent, but only age and smoking were associated with catheterization-proven coronary artery disease in this group. We conclude that coronary artery disease is common in black men evaluated for chest pain but less frequent than would be expected from comparison with findings in white men presenting similar clinical features. Risk factors other than age and smoking were not associated with increased incidence of disease. A prospective study is needed to delineate a more effective means of evaluating black male patients with chest pain.

Human immunodeficiency virus infection: knowledge of the disease and attitudes toward related issues and policies among health care workers in a low-incidence nonurban hospital.

We compared the knowledge and attitudes regarding human immunodeficiency virus (HIV) infection among employees in a tertiary care teaching hospital in a nonurban southeastern city with a relatively low incidence of acquired immunodeficiency syndrome (AIDS). All 260 physicians and a random sample of 240 other employees were asked to complete a 59-item anonymous mail survey. All groups of respondents, including physicians, showed a lack of understanding of critical aspects of AIDS, particularly transmission. Negative attitudes such as victim blaming and not liking to care for persons with HIV infection were common, especially among house staff and respondents who do not give hands-on care. Misinformation, aversion, fear, and lack of compassion were evidenced by a substantial proportion of the respondents, particularly house staff. The attitudes expressed suggest that there is more focus on the rights of the caregiver than on the welfare of patients. These findings show that there is a need for medical education that focuses on both knowledge and affective issues of HIV infection.

Endoscopic cleaning and disinfection procedures for preventing iatrogenic spread of human immunodeficiency virus.

With estimates as high as 1.8 million individuals infected with human immunodeficiency virus (HIV) in the United States, the majority asymptomatic, it is crucial that all physicians routinely use adequate disinfection procedures for medical instruments. The protosigmoidoscopic disinfection procedures used by US family physicians were evaluated for adequacy in inactivating HIV. Sixty-seven percent of 1,585 randomly selected American Academy of Family Physicians members completed a mail survey regarding these procedures. Comparing procedures used with those recommended by the Centers for Disease Control or documented to inactivate HIV, 32.4 percent were judged to be appropriate procedures; 54.4 percent of the procedures were not tested or recommended; and 13.2 percent used appropriate solutions but at inadequate concentrations or exposure times. Therefore, a substantial proportion of US family physicians performing endoscopic procedures use disinfection procedures that may not inactivate HIV. The ever-increasing prevalence of HIV demands that standardized adequate disinfection procedures be implemented by all physicians to prevent the potential nosocomial spread of HIV.

Use of rigid and flexible sigmoidoscopy by family physicians in the United States.

To investigate the incidence of use of the flexible and rigid proctosigmoidoscopes by family physicians, a questionnaire was mailed to 1,585 randomly selected members of the American Academy of Family Physicians. Of the total of 1,057 respondents, 48 percent performed sigmoidoscopy, with 30 percent performing flexible sigmoidoscopy, 31 percent performing rigid sigmoidoscopy, and 48 percent performing at least one of the procedures. Younger physicians were found to be more likely to perform flexible sigmoidoscopy, as were physicians who practice in communities of fewer than 500,000 population. Nationwide, more of the flexible procedures are performed in private offices than in the hospital. Physicians in communities of less than 500,000, however, are more likely to use the flexible sigmoidoscope in a hospital setting than are physicians in larger urban areas [corrected]. Board-certified physicians were more likely to perform one or both procedures than were noncertified physicians.