Micaela H. Coady

A Randomized Intervention Trial to Reduce the Lending of Used Injection Equipment Among Injection Drug Users Infected With Hepatitis C

OBJECTIVES We evaluated the efficacy of a peer-mentoring behavioral intervention designed to reduce risky distributive injection practices (e.g., syringe lending, unsafe drug preparation) among injection drug users with hepatitis C virus (HCV) infection. METHODS A randomized trial with a time-equivalent attention-control group was conducted among 418 HCV-positive injection drug users aged 18 to 35 years in 3 US cities. Participants reported their injection-related behaviors at baseline and at 3- and 6-month follow-ups. RESULTS Compared with the control group, intervention-group participants were less likely to report distributive risk behaviors at 3 months (odds ratio [OR]=0.46; 95% confidence interval [CI]=0.27, 0.79) and 6 months (OR=0.51; 95% CI=0.31, 0.83), a 26% relative risk reduction, but were no more likely to cite their HCV-positive status as a reason for refraining from syringe lending. Effects were strongest among intervention-group participants who had known their HCV-positive status for at least 6 months. Peer mentoring and self-efficacy were significantly increased among intervention-group participants, and intervention effects were mediated through improved self-efficacy. CONCLUSIONS This behavioral intervention reduced unsafe injection practices that may propagate HCV among injection drug users.

Housing status and associated differences in HIV risk behaviors among young injection drug users (IDUs).

Using cross-sectional analysis we examined residential status and associated differences in HIV risk behaviors among 3266 young IDUs enrolled in an HIV prevention trial. A three-level outcome (homeless (37%), equivocally housed (17%), housed (46%)) was defined based on responses to two questions assessing subjective and objective criteria for homelessness: “equivocally housed” participants were discordant on these measures. In multivariate analysis, antecedents of homelessness were having lived in an out-of-home placement, been thrown out of the home or in juvenile detention, and experienced childhood abuse; while correlates included receiving income from other and illegal sources, drinking alcohol or using methamphetamine at least daily, using shooting galleries, backloading, and sex work. A subset of these variables was associated with being equivocally housed. HIV risk varies by housing status, with homeless IDUs at highest risk. Programs for IDUs should utilize a more specific definition of residential status to target IDUs needing intervention.

Strategies for Improving Influenza Immunization Rates among Hard-to-Reach Populations

Whereas considerable attention has been devoted to achieving high levels of influenza immunization, the importance of this issue is magnified by concern over pandemic influenza. Most recommendations for vaccine administration address high risk groups such as the elderly and those with chronic diseases, but coverage for hard-to-reach (HTR) populations has had less attention. HTR populations include minorities but also include other primarily urban groups such as undocumented immigrants, substance users, the homeless, and homebound elderly. Obstacles to the provision of immunization to HTR populations are present at the patient, provider, and structural levels. Strategies at the individual level for increasing immunization coverage include community-based educational campaigns to improve attitudes and increase motivation for receiving vaccine; at the provider level, education of providers to encourage immunizations, improving patient–provider interactions, broadening the provider base to include additional nurses and pharmacists, and adoption of standing orders for immunization administration; and at the structural level, promoting wider availability of and access to vaccine. The planning process for an influenza pandemic should include community engagement and extension of strategies beyond traditional providers to involve community-based organizations addressing HTR populations.

Project VIVA: A Multilevel Community-Based Intervention to Increase Influenza Vaccination Rates Among Hard-to-Reach Populations in New York City

OBJECTIVES We sought to determine whether the work of a community-based participatory research partnership increased interest in influenza vaccination among hard-to-reach individuals in urban settings. METHODS A partnership of researchers and community members carried out interventions for increasing acceptance of influenza vaccination in disadvantaged urban neighborhoods, focusing on hard-to-reach populations (e.g., substance abusers, immigrants, elderly, sex workers, and homeless persons) in East Harlem and the Bronx in New York City. Activities targeted the individual, community organization, and neighborhood levels and included dissemination of information, presentations at meetings, and provision of street-based and door-to-door vaccination during 2 influenza vaccine seasons. Participants were recruited via multiple modalities. Multivariable analyses were performed to compare interest in receiving vaccination pre- and postintervention. RESULTS There was increased interest in receiving the influenza vaccine postintervention (P<.01). Being a member of a hard-to-reach population (P=.03), having ever received an influenza vaccine (P<.01), and being in a priority group for vaccination (P<.01) were also associated with greater interest in receiving the vaccine. CONCLUSIONS Targeting underserved neighborhoods through a multilevel community-based participatory research intervention significantly increased interest in influenza vaccination, particularly among hard-to-reach populations. Such interventions hold promise for increasing vaccination rates annually and in pandemic situations.

Evaluating New York City’s Smoke-Free Parks and Beaches Law: A Critical Multiplist Approach to Assessing Behavioral Impact

This article describes the evaluation of the law banning smoking in New York City’s parks and beaches that went into effect in 2011. We discuss the practical and methodological challenges that emerged in evaluating this law, and describe how we applied the principles of critical multiplism to address these issues. The evaluation uses data from three complementary studies, each with a unique set of strengths and weaknesses that can provide converging evidence for the effectiveness of the law. Results from a litter audit and an observational study suggest the ban reduced smoking in parks and beaches. The purpose, methodology and baseline results from an ongoing survey that measures how frequently adults in NYC and across New York State notice people smoking in parks and on beaches are presented and discussed. Limitations are considered and suggestions are offered for future evaluations of similar policies.

Rapid Vaccine Distribution in Nontraditional Settings: Lessons Learned From Project VIVA

With growing fear of a worldwide influenza pandemic, programs that can rapidly vaccinate a broad range of persons are urgently needed. Vaccination rates are low among disadvantaged and hard-to-reach populations living within urban communities, and delivering vaccines to these groups may prove challenging. Project VIVA 1 (Venue-Intensive Vaccination for Adults), staffed by teams of nurses and outreach workers, aimed to deliver vaccines rapidly within disadvantaged neighborhoods in New York City. Project VIVA nurses offered free influenza vaccine door-to-door and on street corners over 10 days in October, 2005. A total of 1,648 people were vaccinated, exceeding expectation. Careful selection and training of project staff, community involvement in project development, community outreach, and prioritizing street-based distribution may be key factors in an effective rapid vaccination program. In conclusion, this project may be replicated in other communities and utilized for annual vaccination campaigns and in the event of a pandemic. 1This project was developed by members of the Harlem Community and Academic Partnership (HCAP) and the Center for Urban Epidemiologic Studies (CUES). The VIVA Intervention Working Group members are: Dr. Ann Boyer, Dr. Robert Brackbill, Brian Brown, Jose Caraballo, Karyn London, Gail Love, Pat Monahan, Dr. Erica Phillips, Sarah Sisco, and Dr. Sharon Stancliff. This work was supported by a grant from the National Institute on Drub Abuse (DA017004) and the Merck Foundation.

Predictors of Influenza Vaccination in an Urban Community during a National Shortage

Little is known about the impact of vaccine shortages on vaccination rates among disadvantaged populations in the United States. We compared factors associated with influenza vaccination rates during a vaccine shortage (2004–2005) and a non-shortage (2003–2004) year among adults in predominantly minority New York City neighborhoods. Thirty-one percent of participants received influenza vaccine during the non-shortage year compared with 18% during the shortage. While fewer people received the influenza vaccine during the shortage, a higher proportion of the vaccinated were in a high-risk group (68% vs. 52%, respectively). People were less likely to have been vaccinated during the shortage if they were Black. This study suggests that vaccination rates were lower during the shortage period among Blacks and those who are not explicitly a focus of national vaccination outreach campaigns. Such groups are less likely to be vaccinated when vaccines are scarce.

Access To Influenza Vaccine In East Harlem And The Bronx During A National Vaccine Shortage

In October 2004, one of the major producers of the U.S. influenza vaccine supply announced that their vaccine would not be available because of production problems, resulting in approximately half of the anticipated supply suddenly becoming unavailable. This study was part of a larger effort using community-based participatory research (CBPR) principles to distribute influenza vaccine to hard-to-reach populations. Given the extant literature suggesting economic and racial disparities in influenza vaccine access in times of adequate supply and our inability to distribute vaccine due to the shortage, we sought to examine vaccine access as well as awareness of the vaccine shortage and its impact on health-seeking behaviors in eight racially-diverse and economically-disadvantaged neighborhoods in New York City (NYC) during the shortage. In our study few people had been vaccinated, both among the general community and among high risk groups; vaccination rates for adults in priority groups and non-priority groups were 21.0% and 3.5%. Awareness of the 2004 vaccine shortage was widespread with over 90% being aware of the shortage. While most attributed the shortage to production problems, almost 20% said that it was due to the government not wanting to make the vaccine available. Many respondents said they would be more likely to seek vaccination during the current and subsequent influenza seasons because of the shortage. The target neighborhoods were significantly affected by the national influenza vaccine shortage. This study highlights the challenges of meeting the preventive health care needs of hard-to-reach populations in times of public health crisis.

Asthma Education in a Subsidized Preschool Setting

The Inspire education program, with nine modules, was developed to improve medical management of asthma and was piloted among parents of preschool children in an economically disadvantaged community of color with high asthma prevalence. Program flexibility, individualized educational modules, a case management approach, and institutional involvement were key elements.