Elizabeth L. Dixon

Risk factors for hepatitis C virus infection among homeless adults

OBJECTIVE: To describe the prevalence of hepatitis C virus (HCV) infection in a sample of homeless and impoverished adults and examine risk factors for HCV infection in the overall sample and as a function of injection drug use.DESIGN: Assays were conducted on stored sera. Socio-demographic characteristics and risky sexual activity were measured by content-specific items. Substance use was measured by a structured questionnaire. HCV antibodies were tested by enzyme-linked immunosorbent assay; a confirmatory level was defined by recombinant immunoblot assay.SETTINGS: Shelters (N=36) and outdoor locations in Los Angeles.PARTICIPANTS: Eight hundred eighty-four homeless women and/or partners or friends.RESULTS: Among this sample of 884 homeless and impoverished adults, 22% were found to be HCV infected. Lifetime injection drug users (IDUs) (cocaine, crack, and methamphetamine) and recent daily users of crack were more likely than nonusers or less-frequent users of these drugs to be HCV-infected. Similar results were found for those who had been hospitalized for a mental health problem. Among non-injection drug users and persons in the total sample, those who reported lifetime alcohol abuse were more likely than those who did not to be HCV infected. Controlling for socio-demographic characteristics, multiple logistic regression analyses revealed IDUs have over 25 times greater odds of having HCV infection than non-IDUs. HCV infection was also predicted by older age, having started living on one’s own before the age of 18, and recent chronic alcohol use. Males and recent crack users had about one and a half times greater odds of HCV infection when compared to females and non-chronic crack users.CONCLUSIONS: Targeted outreach for homeless women and their partners, including HCV testing coupled with referrals to HCV and substance abuse treatments, may be helpful.

Health Disparities Among Vulnerable Populations: Evolution of Knowledge Over Five Decades in nursing Research Publications

BackgroundConsiderable attention has been focused recently on conducting research on the health disparities experienced by some Americans as the result of poverty, ethnicity, and/or marginalized social status. Nursing research has a major role to play in developing this body of knowledge. PurposeThe purpose of this paper is to review the contributions that Nursing Research made through its publications over the last five decades in developing the body of tested knowledge about health disparities in vulnerable groups and to analyze the progress made. MethodsCriteria for reviewing the literature were established. All Nursing Research publications between 1952 and 2000 were searched manually, indexes of each year’s bound volumes were reviewed, and computer searches were conducted. Included in the review were research reports, research briefs, and methodology articles. ResultsSeventy-nine papers were found that met basic criteria for inclusion. The number of relevant publications increased each decade, with a sizable increase in numbers since 1990, and may be related to the social, political, and economic climate of each decade. The research questions asked and the methods used became more complex over time. ConclusionsNursing Research has made a significant contribution in disseminating the body of tested knowledge related to the health disparities experienced by vulnerable populations and the methodologies associated with vulnerable populations research. Areas for future research are community-based studies, intervention studies that provide tangible resources, and methodologic approaches that involve participants in the research process.

Community-Partnered Cluster-Randomized Comparative Effectiveness Trial of Community Engagement and Planning or Resources for Services to Address Depression Disparities

ABSTRACTBACKGROUNDDepression contributes to disability and there are ethnic/racial disparities in access and outcomes of care. Quality improvement (QI) programs for depression in primary care improve outcomes relative to usual care, but health, social and other community-based service sectors also support clients in under-resourced communities. Little is known about effects on client outcomes of strategies to implement depression QI across diverse sectors.OBJECTIVETo compare the effectiveness of Community Engagement and Planning (CEP) and Resources for Services (RS) to implement depression QI on clients’ mental health-related quality of life (HRQL) and services use.DESIGNMatched programs from health, social and other service sectors were randomized to community engagement and planning (promoting inter-agency collaboration) or resources for services (individual program technical assistance plus outreach) to implement depression QI toolkits in Hollywood-Metro and South Los Angeles.PARTICIPANTSFrom 93 randomized programs, 4,440 clients were screened and of 1,322 depressed by the 8-item Patient Health Questionnaire (PHQ-8) and providing contact information, 1,246 enrolled and 1,018 in 90 programs completed baseline or 6-month follow-up.MEASURESSelf-reported mental HRQL and probable depression (primary), physical activity, employment, homelessness risk factors (secondary) and services use.RESULTSCEP was more effective than RS at improving mental HRQL, increasing physical activity and reducing homelessness risk factors, rate of behavioral health hospitalization and medication visits among specialty care users (i.e. psychiatrists, mental health providers) while increasing depression visits among users of primary care/public health for depression and users of faith-based and park programs (each p < 0.05). Employment, use of antidepressants, and total contacts were not significantly affected (each p > 0.05).CONCLUSIONCommunity engagement to build a collaborative approach to implementing depression QI across diverse programs was more effective than resources for services for individual programs in improving mental HRQL, physical activity and homelessness risk factors, and shifted utilization away from hospitalizations and specialty medication visits toward primary care and other sectors, offering an expanded health-home model to address multiple disparities for depressed safety-net clients.

Using a Community Partnered Participatory Research Approach to Implement a Randomized Controlled Trial: Planning Community Partners in Care

Quality improvement (QI) for depression in primary care can reduce disparities in outcomes. We describe how community-partnered participatory research was used to design Community Partners in Care, a randomized trial of community engagement to activate a multiple-agency network versus support for individual agencies to implement depression QI in underserved communities.

Predicting positive attitudes about quitting drug and alcohol use among homeless women.

Two separate path models for alcohol and drugs were tested in which psychosocial, environmental, and sociodemographic variables predicted behavioral and substance abuse related factors as well as the key outcome of positive attitudes about quitting drugs (N = 620) or alcohol (N = 526) in a sample of 709 homeless women. A positive attitude about quitting alcohol was predicted by more Addiction Symptoms, fewer Positive Effects from using alcohol and not having a partner who uses alcohol. A positive attitude about quitting drugs was predicted by more Drug Problems, greater Drug Use in the Past 6 Months, more Active Coping, more education, less Emotional Distress, not having a partner who uses drugs, and fewer Addiction Symptoms. Implications of the results for drug and alcohol interventions are discussed.

Hepatitis C virus infection among homeless men referred from a community clinic

In this study of factors related to Hepatitis C virus (HCV) infection in 104 homeless HCV-infected men and 94 uninfected homeless men, findings reveal that homeless men with HCV infection are older and more likely to be cocaine injectors than those not infected. Moreover, the sharing of needles, use of injected cocaine during the past 6 months, previous incarceration, veteran status, fair or poor health, and having multiple tattoos are also associated with HCV infection. Reports of having completed the HBV vaccination series, weekly marijuana use, and snorting cocaine or methamphetamine are negatively associated with HCV infection. Among men not reporting lifetime injection drug use, factors such as sharing toothbrushes, having multiple tattoos, being in fair or poor health, and past incarceration are associated with HCV infection. These findings may need to be considered when making screening decisions and counseling homeless male patients about HCV.

An Implementation Evaluation of the Community Engagement and Planning Intervention in the CPIC Depression Care Improvement Trial

The goal of this paper is to document and evaluate the process of implementing an evidence-based depression intervention in community settings through the use of community-academic partnered approaches. We discuss how and to what extent the goals of community engagement and collaborative planning were achieved in the intervention arm of the Community Partners in Care study that aimed to adapt evidence-based depression care toolkits for diverse agencies in Hollywood and South Los Angeles. We find that partnered research strategies have a potential to effectively engage community members around depression and involve them in intervention planning activities. Our results suggest that successful collaboration among diverse agencies requires that they understand what is expected of them, are comfortable with the role they choose to perform, and have organizational support to contribute to the project. To facilitate the development of collaborative relationships, time and effort should be devoted to explaining how collaboration among diverse agencies may take place.

Community-Partnered Research Conference Model: The Experience of Community Partners in Care Study

The Problem: Conducting community-partnered research conferences is a powerful yet underutilized approach to translating research into practice and improving result dissemination and intervention sustainability strategies. Nonetheless, detailed descriptions of conference features and ways to use them in empirical research are rare.Purpose: We describe how community-partnered conferences may be integrated into research projects by using an example of Community Partners in Care (CPIC), a large, cluster-randomized, controlled, trial (RCT) that uses community-partnered participatory research (CPPR) principles.Key Points: Our conceptual model illustrates the role community-partnered research conferences may play in three study phases and describes how different conference features may increase community engagement, build two-way capacity, and ensure equal project ownership.Conclusions: As the number of community-partnered studies grows, so too does the need for practical tools to support this work. Community-partnered research conferences may be effectively employed in translational research to increase two-way capacity building and promote long-term intervention success.

Generating science by training future scholars in nursing research addressing the needs of vulnerable populations.

This chapter focuses on the National Institutes of Health (NIH) T32 National Research Service Award (NRSA) funding mechanism, designed to enhance the development of nurse scientists. The general history and principles underlying NIH funding for T32s as well as the National Institute of Nursing Research’s (NINR) involvement in the NRSA program is described, highlighting the University of California Los Angeles School of Nursing’s T32 training program in vulnerable populations research and the program and career trajectory data from close to two-thirds of NINR-funded T32s directors. Recommendations for the improvement of NINR-funded T32 training programs are identified. Findings include the need for increased collaboration between institutions receiving T32 funding from the NINR.

The Role of Faith-Based Organizations in the Depression Care of African Americans and Hispanics in Los Angeles

OBJECTIVE This study examined use of depression care provided by faith-based organizations (FBOs) by African Americans and Hispanics and factors associated with the receipt of such care, including mental illness severity and use of traditional mental health services. METHODS The study used baseline data from the Community Partners in Care study, a group-randomized trial comparing a community-partnered approach with a technical-assistance approach to improving depression care in underresourced communities in Los Angeles. A sample of 947 individuals (48% African American, 27% non-U.S.-born Hispanic, 15% U.S.-born Hispanic, and 10% non-Hispanic white) were surveyed about recent visits to a religious or spiritual place and receipt of FBO depression care. Descriptive analyses compared racial-ethnic, sociodemographic, and health service use variables for three groups: those who did not attend a religious place, those who attended a religious place and did not receive FBO depression services, and those who received FBO depression services. Multinomial logistic regression was used to identify predictors of receipt of FBO depression care. RESULTS A larger proportion of African Americans and non-U.S.-born Hispanics received FBO faith-based depression services compared with non-Hispanic whites and with U.S.-born Hispanics. Receipt of FBO depression services was associated with younger age, lifetime diagnosis of mania, use of primary care depression services, and receipt of a mental health service from a substance abuse agency. CONCLUSIONS FBO depression services were used in the community, especially by persons from racial-ethnic minority groups. Collaborative efforts between FBOs and traditional health services may increase access to depression services for African Americans and Latinos.