Lucy Bradley-Springer

The social determinants of health.

Over the course of my career, I have often been confronted with health problems that weren’t health problems. Sometimes I saw these problems in individual patients: an infant with a broken arm whose parents were homeless. Sometimes I saw these problems in communities: high rates of uncontrolled diabetes on Native American reservations where patients couldn’t get to the clinic for care and couldn’t afford their medications. Sometimes I even saw these problems in entire countries: governments that couldn’t (or didn’t) assure that their citizens had food and safe environments in which to live. Of course these aren’t exactly ‘‘non-health’’ issues—we all know that nutrition, clean water, access to care, and the political will to develop population-based health policy are important components of health. But these issues aren’t addressed very well in health care funding, at least not in the United States. My response to these ‘‘non-health’’ problems has often been one of despair—where do we start? How can we possibly address the complex issues of poverty, homelessness, illiteracy, polluted air, contaminated water, lack of transportation, and discrimination when we are also trying to deal with HIVor diabetes or childhood obesity? And, as health care providers who can see the toll these problems take on individual and public health, don’t we have an obligation to address them? The question is how to address such complex issues. Because my father was an advocate for

Enhanced Personal Contact With HIV Patients Improves Retention in Primary Care: A Randomized Trial in 6 US HIV Clinics

BACKGROUND The aim of the study was to determine whether enhanced personal contact with human immunodeficiency virus (HIV)-infected patients across time improves retention in care compared with existing standard of care (SOC) practices, and whether brief skills training improves retention beyond enhanced contact. METHODS The study, conducted at 6 HIV clinics in the United States, included 1838 patients with a recent history of inconsistent clinic attendance, and new patients. Each clinic randomized participants to 1 of 3 arms and continued to provide SOC practices to all enrollees: enhanced contact with interventionist (EC) (brief face-to-face meeting upon returning for care visit, interim visit call, appointment reminder calls, missed visit call); EC + skills (organization, problem solving, and communication skills); or SOC only. The intervention was delivered by project staff for 12 months following randomization. The outcomes during that 12-month period were (1) percentage of participants attending at least 1 primary care visit in 3 consecutive 4-month intervals (visit constancy), and (2) proportion of kept/scheduled primary care visits (visit adherence). RESULTS Log-binomial risk ratios comparing intervention arms against the SOC arm demonstrated better outcomes in both the EC and EC + skills arms (visit constancy: risk ratio [RR], 1.22 [95% confidence interval {CI}, 1.09-1.36] and 1.22 [95% CI, 1.09-1.36], respectively; visit adherence: RR, 1.08 [95% CI, 1.05-1.11] and 1.06 [95% CI, 1.02-1.09], respectively; all Ps < .01). Intervention effects were observed in numerous patient subgroups, although they were lower in patients reporting unmet needs or illicit drug use. CONCLUSIONS Enhanced contact with patients improved retention in HIV primary care compared with existing SOC practices. A brief patient skill-building component did not improve retention further. Additional intervention elements may be needed for patients reporting illicit drug use or who have unmet needs. CLINICAL TRIALS REGISTRATION CDCHRSA9272007.

Feasibility of a daily electronic survey to study prevention behavior with HIV-infected individuals.

The daily experiences of persons living with HIV (PLWH) are important but under-studied as predictors of HIV prevention behavior. Ecological momentary assessment (EMA) is an intensive within-subjects data collection method that can be used to examine daily experiences. To determine whether PLWH would participate in EMA, we conducted a feasibility study with 21 PLWH. The method was acceptable to men and women from diverse backgrounds, with 81% (17/21) completing 2 months of daily surveys, and 67% (14/21) completing 6 months. Measures were completed on 72% of study days. Only 6% of records had missing data. Daily survey completion decreased over time. Participants reported that EMA was easy and did not influence their behaviors. Results suggest EMA is feasible with PLWH.

Recommendations and reality: Perceived patient, provider, and policy barriers to implementing routine HIV screening and proposed solutions

In 2006, the Centers for Diseases Control and Prevention (CDC) released recommendations calling for routine HIV testing to be offered to those ages 13 to 64 as a standard of general health care. This recommendation included a plan to conduct HIV testing as part of a general consent. The reasoning and evidence for this recommendation is supported by experts, patients, and sponsored screenings by the CDC. The rationale behind this approach includes that knowledge of ones HIV status helps (1) infected individuals adopt risk-reduction behaviors and access to life-prolonging treatment and (2) uninfected individuals maintain behaviors that reduce their risk of becoming infected. This article discusses the perceived patient, provider, and policy barriers to implementing routine HIV screening and proposed solutions that can be part of a nurse-led contribution to develop and adopt innovative, patient-centered care models that can address the need for screening.

Outcomes of Multimodal Training for Healthcare Professionals at an AIDS Education and Training Center

There is an ongoing need for continuing professional education (CPE) in the rapidly changing field of HIV care, but the best instructional methods remain a subject of debate. This study assessed the effects of training at an AIDS Education and Training Center (AETC) over an 18-month period. Health care professionals (HCP) who attended more than one training event showed small but significant improvements over time in HIV-related clinical practice behaviors. The type of training also predicted self-reported practice behavior, with interactive trainings and individual consultations associated with greater change, and intensive clinical training activities associated with a faster rate of change but not better scores on the self-reported behavior measure. Participants also reported high levels of satisfaction, knowledge improvement, and intention to change after each training event; however, these results were unrelated to whether trainees actually reported improved practice behavior.

Every nurse is an HIV nurse.

Overview: The evolution of HIV infection into a chronic disease has implications across all clinical care settings. Every nurse should be knowledgeable about the prevention, testing, treatment, and chronicity of the disease in order to provide high-quality care to people with or at risk for HIV. Its important, therefore, to have an understanding of the changing epidemiology of the disease, the most recent testing recommendations, developments in screening technology, the implications of aging with HIV infection, and the nursing implications of the ongoing epidemic.

Improving Anal Cancer Screening in an Ambulatory HIV Clinic: Experience from a Quality Improvement Initiative

Evidence suggests that persons living with HIV (PLWH) are at increased risk for anal cancer. Early detection of anal cancer is an important prevention measure, but screening rates have been low. This report describes the experience of a quality improvement initiative to increase anal cancer screening at an HIV-specialty clinic. Chart reviews were conducted for three time periods: baseline year, prior to program discussion; transition year, during planning; and implementation year, during program availability. Odds ratios using Fishers exact test showed that the odds of receiving anal cancer screening increased significantly in the transition year, odds ratio (OR) = 2.859, 95% confidence interval (CI): [1.798; 4.546], Fishers z = 4.40, p < 0.0001, and in the implementation year, OR = 7.446, 95% CI: [4.783; 11.588], Fishers z > 8.2, p < 0.0001. Patients and clinicians reported high levels of satisfaction with the program. Referring clinicians were also more likely to discuss anal cancer screening.

Changes in Clinician Ability to Assess Risk and Help Patients Determine the Need for Hiv Testing A Comparison of Three Teaching Methods

An estimated one of four people with HIV in the United States do not know they have the infection. The Centers for Disease Control and Prevention encourages HIV testing in clinical settings, but there is evidence that this is not done on a regular basis. The purposes of this study were to (a) compare two less traditional teaching methods with a classroom method to determine whether the less traditional methods resulted in greater improvement of clinician knowledge, skill, and willingness to perform HIV risk assessment as the basis for recommending HIV testing; and (b) find out whether there were significant differences in convenience, cost, learner preference, or learner acceptance that would make one method more desirable than the others. Findings from participants in the standardized patient interaction with facilitator feedback (FB) and the case-based self-study module (SSM) were not different from those of participants in the interactive classroom education method (CL). Generally, there were positive changes in knowledge, attitudes, and behaviors over time. Participants preferred standardized patient interaction (FB) and interactive classes (CL) to self-study modules (SSM).

Political Ideology, HIV Infection, and PEPFAR

Have you read the recent evaluation of the President’s Emergency Plan for AIDS Relief (PEPFAR; Evertz, 2010)? It provides an interesting analysis of successes and problems with PEPFAR as well as an agenda to improve this global initiative to stem the tide of the HIV epidemic. Evertz, the first openly gay appointee of a Republican president, served in two different HIV-related positions in the BushWhite House. His analysis of PEPFAR comes from an insider’s perspective, but his comments are tempered by a pragmatism that was not often applied to HIV during the previous administration.

Predatory Publishing and You

Once upon a time there was an academic librarian at the University of Colorado who led a quiet librarian life until the day he noticed predators in the midst of scholarly publishing. Jeffrey Beall discovered, studied, revealed, and blogged about what he would eventually name Predatory Publishing. His Web site, Scholarly Open Access (http:// scholarlyoa.com), is an increasingly important source of information for authors and readers from all professional walks of life, including nurses (Pearson, 2015), but more about that later.