Serena Rajabiun

Health literacy of HIV-positive individuals enrolled in an outreach intervention: results of a cross-site analysis.

This article examines health literacy among a group a HIV-positive persons at risk for receiving suboptimal health care due to histories of substance abuse, mental illness, incarceration, and unstable housing or homelessness. Participants receiving services from three outreach programs funded as part of a multisite demonstration project were screened for health literacy using the Test of Functional Health Literacy in Adults (TOFHLA) at program enrollment. The goal of this analysis was to identify demographics, risk factors, and health indicators associated with different levels of health literacy. Results indicated that although fewer than 30% of the sample scored in the marginal or inadequate range for health literacy, participants with these lower levels of health literacy were more likely to be African American or Latino/a, heterosexual, speak Spanish as their primary language, and have less than a high school education. The disparities in health literacy found in this study point to a need to assess level of health literacy and provide culturally sensitive health literacy interventions for persons with chronic diseases such as HIV. In addition to offering these services within HIV health care settings, health professionals can use other potential venues for health literacy assessment and intervention including substance abuse treatment and community-based social service, education, and training programs. Health care and support service providers also must become aware of the importance of health literacy when caring for all patients with HIV, particularly those most likely to have low health literacy.

Increasing Access to Oral Health Care for People Living with HIV/AIDS in the U.S.: Baseline Evaluation Results of the Innovations in Oral Health Care Initiative

Objectives. We provide an overview of the Health Resources and Services Administration HIV/AIDS Bureaus Special Projects of National Significance Innovations in Oral Health Care Initiative, describe the models developed by the 15 demonstration sites and associated evaluation center, and present initial descriptive data about the characteristics of the multisite evaluation study sample. Methods. Baseline data were collected from May 2007–August 2009 for 2,469 adults living with HIV/AIDS who had been without dental care, except for emergency care, for 12 months or longer. Variables included sociodemographic characteristics, HIV status, medical care, history of dental care and oral health symptoms, oral health practices, and physical and mental health quality of life. Descriptive statistics of baseline variables were calculated. Results. The study sample included 2,469 adults who had been HIV-positive for a decade; most were engaged in HIV care. The majority (52.4%) of patients had not seen a dentist in more than two years; 48.2% reported an unmet oral health-care need since testing positive for HIV, and 63.2% rated the health of their teeth and gums as “fair” or “poor.” Conclusions. This study is the largest to examine oral health care among people living with HIV/AIDS in more than a decade. The need for access to oral health care among members of this HIV-positive patient sample is greater than in the general population, following previous trends. Findings from our study reinforce the necessity for continued federal and statewide advocacy and support for oral health programs targeting people living with HIV/AIDS; findings can be extended to other vulnerable populations.

Patient perspectives on improving oral health-care practices among people living with HIV/AIDS.

This qualitative study explored the impact on oral health-care knowledge, attitudes, and practices among 39 people living with HIV/AIDS (PLWHA) participating in a national initiative aimed at increasing access to oral health care. Personal values and childhood dental experiences, beliefs about the importance of oral health in relation to HIV health, and concerns for appearance and self-esteem were found to be determinants of oral health knowledge and practice. Program participation resulted in better hygiene practices, improved self-esteem and appearance, relief of pain, and better physical and emotional health. In-depth exploration of the causes for these changes revealed a desire to continue with dental care due to the dental staff and environmental setting, and a desire to maintain overall HIV health, including oral health. Our findings emphasize the importance of addressing both personal values and contextual factors in providing oral health-care services to PLWHA.

The Role of Patient Navigators in Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations.

Context: People living with human immunodeficiency virus (HIV) (PLWH) who are most at risk for falling out of HIV primary care and detectable viral loads include homeless and unstably housed individuals and those codiagnosed with behavioral health disorders. The patient-centered medical home (PCMH) is a model that promotes provision of comprehensive, patient-centered, accessible, coordinated, and quality care for patients. This initiative provided patient navigation to HIV-positive homeless and unstably housed individuals codiagnosed with a mental health or substance use disorder as a means to create an adapted PCMH to meet the specific needs of this population. Objective: The purpose of this analysis was to characterize the roles and responsibilities of patient navigators as part of an effort to create a medical home for homeless and unstably housed PLWH with behavioral health comorbidities. Design: Eighty-one in-depth interviews with clinic staff and 2 focus groups with patient navigators were conducted. Content analysis was performed to identify key roles and responsibilities of the patient navigators. Results: Patient navigators played an important role in creating a PCMH by working with clients to schedule and complete appointments, develop comprehensive care plans, forging critical relationships with providers both within and outside of health care systems, providing holistic support to increase patient self-management, and assisting in achieving housing stability. Conclusions: It may be necessary to adapt the traditional PCMH model to effectively meet the social, behavior health, and medical needs of homeless and unstably housed PLWH with behavioral health comorbidities. A patient navigator who can invest time in supporting and connecting these patients to needed services may be a key component in creating an effective PCMH for this population. These findings highlight the roles and tasks of patient navigators that may contribute to developing a PCMH specific to homeless and unstably housed PLWH with mental health and substance use comorbidities. Implementation of such a model has the potential to improve health outcomes (such as retention in care and viral suppression) for particularly vulnerable PLWH and thereby reduce the burden of HIV infection.

Capsule Commentary on Chan et al., The Effect of a Care Transition Intervention on the Patient Experience of Older, Multi-lingual Adults in the Safety Net: Results of a Randomized Controlled Trial.

The standardized HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey does not capture patient- and provider-level contextual factors. This makes the survey susceptible to a range of different interpretations by respondents.1 Utilization of patient-centered interventions may improve HCAHPS scores. Chan assesses the impact of receipt of inpatient and post-discharge phone calls by language-concordant providers to reinforce the care plan and to address acute complaints on patient experiences as assessed by HCAHPS.T he standardized HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey does not capture patientand provider-level contextual factors. This makes the survey susceptible to a range of different interpretations by respondents. Utilization of patient-centered interventions may improve HCAHPS scores. Chan assesses the impact of receipt of inpatient and post-discharge phone calls by language-concordant providers to reinforce the care plan and to address acute complaints on patient experiences as assessed by HCAHPS. When discussing any intensive intervention shown not to have a significant impact, it is helpful to think about the context of patient readiness to accept the intervention support. In true person-centered care, the impetus for the intervention would come from a patient’s request for support. One factor Chan et al. do not address is social support. A similar article with a negative intervention result found that social support may be a key factor in determining patient readiness to accept and use intervention help. Chan’s study suggests a critical aspect for health care systems designing and implementing post-hospitalization programs for elderly populations with low literacy and cognitive impairment. Brief education interventions postdischarge may be insufficient to overcome challenges affecting adherence to care plans once the patient returns home. Involving family and other caregivers in care planning may improve adherence and prevent rehospitalization. For elderly patients with limited social support, care transition programs may also need to move beyond the hospital walls by partnering with community-based agencies to conduct home visits, provide support, and make referrals for necessary medical and psychosocial services. Randomization, as in Chan’s study, is critical, as it can control for potential confounding. However, Chan’s study was a negative trial. Findings from such studies often inform localand national-level policy decisions; thus the import of identification and control of possible confounders is clear and would benefit from a large-scale multi-site study design. Future randomized controlled trials need to identify and address critical contextual factors such as social support and additional nuances not captured by standardized survey instruments, as this may be essential for the success of interventions delivered to distinct subpopulations of patients.