Assessment of readiness to initiate antiretroviral therapy

An important factor in determining a patient's adherence to antiretroviral therapy is the patient's commitment to follow the regimen. This suggests that therapy should be initiated when the patient is willing to commit to the regimen. Starting when the patient is ready may be more important than the laboratory values suggested by various guidelines. In order to increase understanding of patient readiness for antiretroviral therapy HIV infected patients were surveyed to determine the factors that influenced their decision to initiate antiretroviral therapy and to continue to adhere to therapy once started. A sample of 83 HIV infected patients who were currently on antiretroviral regimens completed a 25-item investigator-developed questionnaire. The questionnaire sought information on the length of time from learning of HIV positive status and readiness to initiate therapy. The questionnaire also addressed demographic, psychological and social factors thought to be associated with readiness for adhering to therapy. (Abstract shortened by UMI.)^

Adolescent Pregnancy Prevention in San Jose, Costa Rica : Assessment of an Educational Intervention

This thesis explores adolescent pregnancy in San Jose, Costa Rica and examines a school-based pregnancy prevention intervention. The relationships between school, gender and risk of adolescent pregnancy are also analyzed, and recommendations are made for effective pregnancy prevention programming. The Purral region of Guadalupe on the outskirts of San Jose, Costa Rica, suffers a higher rate of adolescent pregnancy compared to the rest of the country. In response to this problem, the International Health Central American Institute (IHCAI) implemented a sexual health education program in two local secondary schools in 2006. Very little information about the program is available. It is known that the program was initially evaluated through assessments of the participants’ knowledge before and after the educational sessions. There was no evaluation of the youth attitudes or behaviors, adolescent pregnancies, or long-term impact. The author worked with IHCAI in San Jose, Costa Rica to perform an assessment of the longer term effects of this sexual health education program. They developed a questionnaire to evaluate the knowledge, attitudes, and behaviors surrounding sexual health of youth in the Purral community. Researchers at IHCAI later used this survey to collect data from adolescents who had participated in the educational intervention and those who had not. This thesis analyzes the data collected by IHCAI to assess the effectiveness of the - 2 - educational intervention and the influence of other factors on the knowledge, attitudes, and behaviors of adolescents in the Purral region. The thesis begins with an overview of adolescent pregnancy, Costa Rica and the Purral region, and a description of the education intervention implemented by IHCAI. The research goal, logic model, and methods are then described. The results are reported, and the thesis then concludes with discussion of the results as well as study limitations and recommendations for future research and intervention. This thesis will be used to guide IHCAI’s continuation and expansion of adolescent pregnancy prevention programming.

An assessment of the nutritional status of orphaned adolescents living in Nyanza Province, Kenya

Increasing numbers of children and adolescents are becoming vulnerable or orphaned due to the HIV/AIDS epidemic in Nyanza Province, Kenya. Research indicates food security remains a top concern for those caring for these children or adolescents. This study was a examined thinness, stunting, and perceptions about food availability in adolescents ages 10-17 years in Nyanza Province. No evidence was found suggesting orphaned adolescents experience greater amounts of stunting or thinness over non-orphaned adolescents in the province. Orphans did not perceive less available food in their households. Instead, predictors of thinness, stunting, or low perceptions of food availability included age, household facilities, perceptions of equal or unequal treatment in the household, and perceptions about the household's ability to provide them with basic needs. Findings suggest interventions aimed at decreasing malnutrition focus less on orphaned versus non-orphaned adolescents, but they should focus on adolescents made vulnerable due to lower socioeconomic status. ^

The application of latent variable models to the assessment of determinants of HIV risk behavior

Studies on the relationship between psychosocial determinants and HIV risk behaviors have produced little evidence to support hypotheses based on theoretical relationships. One limitation inherent in many articles in the literature is the method of measurement of the determinants and the analytic approach selected. ^ To reduce the misclassification associated with unit scaling of measures specific to internalized homonegativity, I evaluated the psychometric properties of the Reactions to Homosexuality scale in a confirmatory factor analytic framework. In addition, I assessed the measurement invariance of the scale across racial/ethnic classifications in a sample of men who have sex with men. The resulting measure contained eight items loading on three first-order factors. Invariance assessment identified metric and partial strong invariance between racial/ethnic groups in the sample. ^ Application of the updated measure to a structural model allowed for the exploration of direct and indirect effects of internalized homonegativity on unprotected anal intercourse. Pathways identified in the model show that drug and alcohol use at last sexual encounter, the number of sexual partners in the previous three months and sexual compulsivity all contribute directly to risk behavior. Internalized homonegativity reduced the likelihood of exposure to drugs, alcohol or higher numbers of partners. For men who developed compulsive sexual behavior as a coping strategy for internalized homonegativity, there was an increase in the prevalence odds of risk behavior. ^ In the final stage of the analysis, I conducted a latent profile analysis of the items in the updated Reactions to Homosexuality scale. This analysis identified five distinct profiles, which suggested that the construct was not homogeneous in samples of men who have sex with men. Lack of prior consideration of these distinct manifestations of internalized homonegativity may have contributed to the analytic difficulty in identifying a relationship between the trait and high-risk sexual practices. ^

The role of social support in HIV prevention among young Latino men who have sex with men

The purpose of this formative study was to determine and prioritize the HIV-prevention needs of Latino young men who have sex with men (YMSM) in Chihuahua (Mexico), Texas, and California, based on YMSM and service provider perceptions of the factors affecting the assimilation and implementation of HIV-preventive behaviors. These factors included: perceived social support, identification of the modes of HIV transmission, perceived risk of HIV, perceived norms and attitudes of peers.^ The study, drawn from a secondary data set, was a convenience sample of providers (n=8) and clients (n=15). Participants completed face-to face interviews and a survey instrument. Interviews were analyzed to identify common themes and congruence among client groups, and among clients and providers. Providers’ understanding of theoretical constructs of interventions was also assessed. Survey data were analyzed to determine variable frequencies and their congruence to the qualitative analysis. ^ The results revealed several differences and many commonalities in the assimilation of protective messages. Client and provider perceptions were congruent across all domains. Providers demonstrated intuitive command of theoretical concepts but inconsistently verbalized their application. Both clients and providers recognized Latinos possessed high HIV-knowledge levels, despite inconsistent protective behaviors. Clients and providers consistently identified important reasons leading to inconsistent protective behaviors, such as: lack of access to targeted information and condoms, self-esteem, sexual identification, situational factors, decreased perceived HIV-risk, and concerns about homophobia, stigma, and rejection. Other factors included: poverty, failure to reach disenfranchised populations, and lack of role models/positive parental figures. The principal conclusion of the study was that there is a need for further study to understand the interrelationship between larger socioeconomic issues and consistent protective behaviors.^

A critical assessment of the National Institutes of Health Consensus Development Program against the eras which shaped it

This research study offers a critical assessment of NIH's Consensus Development Program (CDP), focusing upon its historical and valuative bases and its institutionalization in response to social and political forces. The analysis encompasses systems-level, as well as interpersonal factors in the adoption of consensus as the mechanism for resolving scientific controversies in clinical practice application. Further, the evolution of the CDP is also considered from an ecological perspective as a reasoned adaptation by NIH to pressures from its supporters and clients for translating biomedical research into medical practice. The assessment examines federal science policy and institutional designs for the inclusion of the public interest and democratic deliberation.^ The study relies on three distinct approaches to social research. Conventional historical methods were utilized in the interpretation of social and political influences across eras on the evolution of the National Institutes of Health and its response to demands for accountability and relevance through its Consensus Development Program. An embedded single-case study was utilized for an empirical examination of the CDP mechanism through five exemplar conferences. Lastly, a sociohistorical approach was taken to the CDP in order to consider its responsiveness to the values of the eras which created and shaped it. An exploration of organizational behavior with considerations for institutional reform as a response to continuing political and social pressure, it is a study of organizational birth, growth, and response to demands from its environment. The study has explanatory import in its attempt to account for the creation, timing, and form of the CDP, relative to political, institutional, and cultural pressures, and predictive import thorough its historical view which provides a basis for informed speculation on the playing out of tensions between extramural and intermural scientists and the current demands for health care reform. ^

A qualitative and quantitative assessment of cancer patients' perceptions of barriers to treatment

This study examined barriers that cancer patients experience in obtaining treatment. The principal aim of the study was to conduct a comprehensive quantitative and qualitative assessment of barriers to cancer treatment for Texas cancer patients. The three specific aims of the study were to: (1) conduct a review and critique of published and unpublished research on barriers to cancer treatment; (2) conduct focus groups for the qualitative assessment of cancer patients' perceived barriers to cancer treatment; and (3) survey a representative sample of cancer patients regarding perceived barriers to treatment. The study was guided by the Aday and Andersen access framework of predisposing, enabling, and need determinants of care-seeking.^ To address the first specific aim, a total of 732 abstracts were examined, from which 154 articles were selected for review. Of these 154 articles, 57 that related directly to research on barriers to cancer treatment were chosen for subsequent analysis. Criteria were applied to each article to evaluate the strength of the study design, sampling and measurement procedures. The major barriers that were consistently documented to influence whether or not cancer patients sought or continued required treatment included problems with communication between the patient and provider, lack of information on side effects, the cost of treatment and associated difficulties in obtaining and maintaining insurance coverage, and the absence of formal and informal networks of social support. Access barriers were generally greater for older, minority women, and patients of lower socioeconomic status.^ To address the second specific aim, a total of eight focus groups (n = 44) were conducted across the State of Texas with cancer patients identified by the Texas Community Oncology Network, American Cancer Society, and community health centers. One important finding was that cost is the greatest hurdle that patients face. Another finding was that with the health care/insurance crisis, an increasing number of physicians are working with their patients to develop individually-tailored payment plans. For people in rural areas, travel to treatment sites is a major barrier due to the travel costs as well as work time forfeited by patients and their family members. A third major finding was the patients' family and church play important roles in providing social and emotional support for cancer patients.^ To address the third aim, a total of 910 cancer patients were surveyed during October and November, 1993. Approximately 65% of the cancer patients responded to the survey. The findings showed that the major barriers to treatment included costs of medications and diagnostic tests, transportation, lack of social support, problems understanding the written information regarding their disease as well as losing coverage or having higher premiums or copayments once they were diagnosed (particularly among blacks).^ Significant differences in reported barriers were found between racial groups. The minority respondents (i.e., blacks and Hispanics) tended to experience more barriers to treatment compared to the white respondents. More specifically, Hispanics were more likely to report transportation as a barrier to treatment than both white and blacks. Future research is needed to better understand the problems that minority cancer patients experience in receiving treatment. (Abstract shortened by UMI.) ^

Comparison of health behaviors of Mexican American and non -Hispanic White females: Implications for health promotion programs

Hispanics form the second-largest minority group in the United States totaling 22 million people. Health data on this population are sparse and inconsistent. This study seeks to determine use of preventative services and risk factor behaviors of Mexican American and non-Hispanic White females residing in South Texas.^ Baseline data from female respondents in household surveys in six South Texas counties (Ramirez and McAlister, 1988; McAlister et al., 1992) were analyzed to test the following hypotheses: (1) Mexican American and Non-Hispanic White females exhibit different patterns of health behaviors; (2) Mexican American females will exhibit different health behaviors regardless of age; and (3) the differences between Mexican American women and non-Hispanic White females are due to education and acculturation factors.^ Over the past decade, the traditional behaviors of Mexican American females have begun to change due to education, acculturation, and their participation in the labor force. The results from this study identify some of the changes that will require immediate attention from health care providers. Results revealed that regardless of ethnicity, age, education, and language preference, non-Hispanic White females were significantly more likely to participate in preventive screening practices than were Mexican American females. Risk factor analysis revealed a different pattern with Mexican American females significantly more likely to be non-smokers, non-alcoholic drinkers, and to have good fat avoidance practices compared to non-Hispanic White females. However, compared to those who are less-educated or Spanish-speaking, Mexican American females with higher levels of education and preference for speaking English only showed positive and negative health behaviors that were more similar to the non-Hispanic White females. The positive health behaviors that come with acculturation, e.g., more participation in preventive care and more physical activity, are welcome changes. But this study has implications for global health development and reinforces a need for "primordial" prevention strategies to deter the unwanted concomitants of economic development and acculturation. Smoking and drinking behaviors among Mexican American females need to be kept at low levels to prevent increased morbidity and premature deaths in this population. ^

Method for the evaluation of social projects

This instrument was part of the research project "Research on Evaluation of Health and Education Plans and Programs in the Province of Buenos Aires", developed by the of Chair Preventive Psychology of the Psychology course of studies at the School of Humanities and Educational Sciences, National Univer- sity of La Plata (Argentina). The basis for proposing an assessment instrument is the need for a method enabling analysis, systematization of knowledge and the assignment of values distributed into scales and organized in general charts, on social programs. Its main concern is the analysis of health and education programs and projects, restricted to certain specific areas or regions, in search for theoretic trustworthi-ness, methodological accuracy as well as pragmatic operability. This is the result of four years of researching said programs at system, service and community levels.

Method for the evaluation of social projects

This instrument was part of the research project "Research on Evaluation of Health and Education Plans and Programs in the Province of Buenos Aires", developed by the of Chair Preventive Psychology of the Psychology course of studies at the School of Humanities and Educational Sciences, National Univer- sity of La Plata (Argentina). The basis for proposing an assessment instrument is the need for a method enabling analysis, systematization of knowledge and the assignment of values distributed into scales and organized in general charts, on social programs. Its main concern is the analysis of health and education programs and projects, restricted to certain specific areas or regions, in search for theoretic trustworthi-ness, methodological accuracy as well as pragmatic operability. This is the result of four years of researching said programs at system, service and community levels.

Method for the evaluation of social projects

This instrument was part of the research project "Research on Evaluation of Health and Education Plans and Programs in the Province of Buenos Aires", developed by the of Chair Preventive Psychology of the Psychology course of studies at the School of Humanities and Educational Sciences, National Univer- sity of La Plata (Argentina). The basis for proposing an assessment instrument is the need for a method enabling analysis, systematization of knowledge and the assignment of values distributed into scales and organized in general charts, on social programs. Its main concern is the analysis of health and education programs and projects, restricted to certain specific areas or regions, in search for theoretic trustworthi-ness, methodological accuracy as well as pragmatic operability. This is the result of four years of researching said programs at system, service and community levels.

Assessment of energy efficiency and sustainability scenarios in the transport system

Background Energy Policy is one of the main drivers of Transport Policy. A number of strategies to reduce current energy consumption trends in the transport sector have been designed over the last decades. They include fuel taxes, more efficient technologies and changing travel behavior through demand regulation. But energy market has a high degree of uncertainty and the effectiveness of those policy options should be assessed. Methods A scenario based assessment methodology has been developed in the frame of the EU project STEPS. It provides an integrated view of Energy efficiency, environment, social and competitiveness impacts of the different strategies. It has been applied at European level and to five specific Regions. Concluding remarks The results are quite site specific dependent. However they show that regulation measures appear to be more effective than new technology investments. Higher energy prices could produce on their turn a deterioration of competitiveness and a threat for social goals.

Modeling impact assessment of transport policies through a multiregional input-output integrated approach

El objetivo de esta investigación es desarrollar una metodología para estimar los potenciales impactos económicos y de transporte generados por la aplicación de políticas en el sector transporte. Los departamentos de transporte y otras instituciones gubernamentales relacionadas se encuentran interesadas en estos análisis debido a que son presentados comúnmente de forma errónea por la insuficiencia de datos o por la falta de metodologías adecuadas. La presente investigación tiene por objeto llenar este vacío haciendo un análisis exhaustivo de las técnicas disponibles que coincidan con ese propósito. Se ha realizado un análisis que ha identificado las diferencias cuando son aplicados para la valoración de los beneficios para el usuario o para otros efectos como aspectos sociales. Como resultado de ello, esta investigación ofrece un enfoque integrado que incluye un modelo Input-Output de múltiples regiones basado en la utilidad aleatoria (RUBMRIO), y un modelo de red de transporte por carretera. Este modelo permite la reproducción con mayor detalle y realismo del transporte de mercancías que por medio de su estructura sectorial identifica los vínculos de las compras y ventas inter-industriales dentro de un país utilizando los servicios del transporte de mercancías. Por esta razón, el modelo integrado es aplicable a diversas políticas de transporte. En efecto, el enfoque se ha aplicado para estudiar los efectos macroeconómicos regionales de la implementación de dos políticas diferentes en el sistema de transporte de mercancías de España, tales como la tarificación basada en la distancia recorrida por vehículo-kilómetro (€/km) aplicada a los vehículos del transporte de mercancías, y para la introducción de vehículos más largos y pesados de mercancías en la red de carreteras de España. El enfoque metodológico se ha evaluado caso por caso teniendo en cuenta una selección de la red de carreteras que unen las capitales de las regiones españolas. También se ha tenido en cuenta una dimensión económica a través de una tabla Input-Output de múltiples regiones (MRIO) y la base de datos de conteo de tráfico existente para realizar la validación del modelo. El enfoque integrado reproduce las condiciones de comercio observadas entre las regiones usando el sistema de transporte de mercancías por carretera, y que permite por comparación con los escenarios de políticas, determinar las contribuciones a los cambios distributivos y generativos. Así pues, el análisis estima los impactos económicos en cualquier región considerando los cambios en el Producto Interno Bruto (PIB) y el empleo. El enfoque identifica los cambios en el sistema de transporte a través de todos los caminos de la red de transporte a través de las medidas de efectividad (MOEs). Los resultados presentados en esta investigación proporcionan evidencia sustancial de que en la evaluación de las políticas de transporte, es necesario establecer un vínculo entre la estructura económica de las regiones y de los servicios de transporte. Los análisis muestran que para la mayoría de las regiones del país, los cambios son evidentes para el PIB y el empleo, ya que el comercio se fomenta o se inhibe. El enfoque muestra cómo el tráfico se desvía en ambas políticas, y también determina detalles de las emisiones de contaminantes en los dos escenarios. Además, las políticas de fijación de precios o de regulación de los sistemas de transporte de mercancías por carretera dirigidas a los productores y consumidores en las regiones promoverán transformaciones regionales afectando todo el país, y esto conduce a conclusiones diferentes. Así mismo, este enfoque integrado podría ser útil para evaluar otras políticas y otros países en todo el mundo. The purpose of this research is to develop a methodological approach aimed at assessing the potential economic and transportation impacts of transport policies. Transportation departments and other related government parties are interested in such analysis because it is commonly misrepresented for the insufficiency of data and suitable methodologies available. This research is directed at filling this gap by making a comprehensive analysis of the available techniques that match with that purpose. The differences when they are applied for the valuation of user benefits or for other impacts as social matters have been identified. As a result, this research presents an integrated approach which includes both a random utility-based multiregional Input-Output model (RUBMRIO), and a road transport network model. This model accounts for freight transport with more detail and realism because its commodity-based structure traces the linkages of inter-industry purchases and sales that use freight services within a given country. For this reason, the integrated model is applicable to various transport policies. In fact, the approach is applied to study the regional macroeconomic effects of implementing two different policies in the freight transport system of Spain, such as a distance-based charge in vehicle-kilometer (€/km) for Heavy Goods Vehicles (HGVs), and the introduction of Longer and Heavier Vehicles (LHVs) in the road network of Spain. The methodological approach has been evaluated on a case by case basis considering a selected road network of highways linking the capitals of the Spanish regions. It has also considered an economic dimension through a Multiregional Input Output Table (MRIO) and the existing traffic count database used in the model validation. The integrated approach replicates observed conditions of trade among regions using road freight transport systems that determine contributions to distributional and generative changes by comparison with policy scenarios. Therefore, the model estimates economic impacts in any given area by considering changes in Gross Domestic Product (GDP), employment (jobs), and in the transportation system across all paths of the transport network considering Measures of effectiveness (MOEs). The results presented in this research provide substantive evidence that in the assessment of transport policies it is necessary to establish a link between the economic structure of regions and the transportation services. The analysis shows that for most regions in the country, GDP and employment changes are noticeable when trade is encouraged or discouraged. This approach shows how traffic is diverted in both policies, and also provides details of the pollutant emissions in both scenarios. Furthermore, policies, such as pricing or regulation of road freight transportation systems, directed to producers and consumers in regions will promote different regional transformations across the country, and this lead to different conclusions. In addition, this integrated approach could be useful to assess other policies and countries worldwide.

Integrated assessment of policy interventions for promoting sustainable irrigation in semi-arid environments: A hydro-economic modeling approach

Sustaining irrigated agriculture to meet food production needs while maintaining aquatic ecosystems is at the heart of many policy debates in various parts of the world, especially in arid and semi-arid areas. Researchers and practitioners are increasingly calling for integrated approaches, and policy-makers are progressively supporting the inclusion of ecological and social aspects in water management programs. This paper contributes to this policy debate by providing an integrated economic-hydrologic modeling framework that captures the socio-economic and environmental effects of various policy initiatives and climate variability. This modeling integration includes a risk-based economic optimization model and a hydrologic water management simulation model that have been specified for the Middle Guadiana basin, a vulnerable drought-prone agro-ecological area with highly regulated river systems in southwest Spain. Namely, two key water policy interventions were investigated: the implementation of minimum environmental flows (supported by the European Water Framework Directive, EU WFD), and a reduction in the legal amount of water delivered for irrigation (planned measure included in the new Guadiana River Basin Management Plan, GRBMP, still under discussion). Results indicate that current patterns of excessive water use for irrigation in the basin may put environmental flow demands at risk, jeopardizing the WFD s goal of restoring the ?good ecological status? of water bodies by 2015. Conflicts between environmental and agricultural water uses will be stressed during prolonged dry episodes, and particularly in summer low-flow periods, when there is an important increase of crop irrigation water requirements. Securing minimum stream flows would entail a substantial reduction in irrigation water use for rice cultivation, which might affect the profitability and economic viability of small rice-growing farms located upstream in the river. The new GRBMP could contribute to balance competing water demands in the basin and to increase economic water productivity, but might not be sufficient to ensure the provision of environmental flows as required by the WFD. A thoroughly revision of the basin s water use concession system for irrigation seems to be needed in order to bring the GRBMP in line with the WFD objectives. Furthermore, the study illustrates that social, economic, institutional, and technological factors, in addition to bio-physical conditions, are important issues to be considered for designing and developing water management strategies. The research initiative presented in this paper demonstrates that hydro-economic models can explicitly integrate all these issues, constituting a valuable tool that could assist policy makers for implementing sustainable irrigation policies.

Assessment of innovative measures implemented in European bus systems using key performance indicators

This paper reports the results of the assessment of a range of measures implemented in bus systems in five European cities to improve the use of public transport by increasing its attractiveness and enhancing its image in urban areas. This research was conducted as part of the EBSF project (European Bus System of the Future) from 2008 to 2012. New buses (prototypes), new vehicle and infrastructure technologies, and operational best practices were introduced, all of which were combined in a system approach. The measures were assessed using multicriteria analysis to simultaneously evaluate a certain number of criteria that need to be aggregated. Each criterion is measured by one or more key performance indicators (KPI) calculated in two scenarios (reference scenario, with no measure implemented; and project scenario, with the implementation of some measures), in order to evaluate the difference in the KPI performance between the reference and project scenario. The results indicate that the measures produce a greater benefit in issues related to bus system productivity and customer satisfaction, with the greatest impact on aspects of perceptions of comfort, cleanliness and quality of service, information to passengers and environmental issues. The study also reveals that the implementation of several measures has greater social utility than very specific and isolated measures.