Residential Segregation and Latino, Black and White Mortality in New York City

Although racial segregation is associated with health status, few studies have examined this relationship among Latinos. We examined the effect of race/ethnic group concentration of Latinos, blacks and whites on all-cause mortality rates within a highly segregated metropolitan area, New York City (NYC). We linked NYC mortality records from 1999 and 2000 with the 2000 U.S. Census data by zip code area. Age-adjusted mortality rates by race/ethnic concentration were calculated. Linear regression was used to determine the association between population characteristics and mortality. Blacks living in predominantly black areas had lower all-cause mortality rates than blacks living in other areas regardless of gender (1616/100,000 vs. 2014/100,000 for men; 1032/100,000 vs. 1362/100,000 for women). Amongst whites, those living in predominantly white areas had the lowest mortality rates. Latinos living in predominantly Latino areas had lower mortality rates than those in predominantly black areas (1187/100,000 vs.1950/100,000 for men; 760/100,000 vs. 779/100,000 for women). After adjustment for socioeconomic conditions, whites, older blacks, and young Latino men experienced decreasing mortality rates when living in areas with increasing similar race/ethnic concentrations. Increasing residential concentration of blacks is independently associated with lower mortality in older blacks; similarly, increasing residential concentration of Latinos and whites is associated with lower mortality in young Latino men and whites, respectively.Inagami and Asch are with the Veterans Affairs, VA Greater Los Angeles Health Care System, Division of General Internal Medicine (111G), 11301 Wilshire Blvd, Los Angeles, CA 90073, USA; Borrell is with the Columbia University, Mailman School of Public Health, 600 West 168th Street, PH 18-331, New York, NY 10032, USA; Wong, Shapiro, and Asch are with the Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, 911 Broxton Plaza, Los Angeles, CA 90095-1736, USA; Fang is with the Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Center for Disease Control and Prevention, 4770 Buford Hwy. NE, MS K-47, Atlanta, GA 30341-3717, USA; Asch is with the RAND Health, Division of General Internal Medicine (111G), 11301 Wilshire Blvd, Los Angeles, CA 90073, USA.     

Pathways to Health Risk Exposure in Adult Film Performers

Despite being part of a large and legal industry in Los Angeles, little is known about adult film performers’ exposure to health risks and when and how these risks might occur. The objective was to identify exposure to physical, mental, and social health risks and the pathways to such risks among adult film performers and to determine how risks differ between different types of performers, such as men and women. Semi-structured in-depth interviews were conducted with 18 female and ten male performers as well as two key informants from the industry. Performers and key informants were recruited through Protecting Adult Welfare, adult film venues, and snowball sampling. Performers engaged in risky health behaviors that included high-risk sexual acts that are unprotected, substance abuse, and body enhancement. They are exposed to physical trauma on the film set. Many entered and left the industry with financial insecurity and suffered from mental health problems. Women were more likely than men to be exposed to health risks. Adult film performers, especially women, are exposed to health risks that accumulate over time and that are not limited to sexually transmitted diseases. At the time of the study, Grudzen was with the Robert Wood Johnson Clinical Scholars Program at the University of California, Los Angeles, Los Angeles, CA, USA; Grudzen is now with the Department of Emergency Medicine, Mt. Sinai School of Medicine, New York, NY, USA; Ryan is with the RAND Corporation, Santa Monica, CA, USA: Margold is with Protecting Adult Welfare, Sherman Oaks, CA, USA; Torres is with the School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA; Gelberg is with the Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA     

Long-Term Morbidity and Mortality among a Sample of Cocaine-Dependent Black and White Veterans

Racial minorities generally exhibit worse health status than do whites. To assess the presence of similar phenomena among long-term cocaine-using veterans, this study examined racial variations in mortality and health status among cocaine-dependent men who were originally recruited at their admissions to cocaine treatment in 1988–1989 and were interviewed approximately 12 years later in 2002–2003. Mortality was higher among whites (15%) than blacks (6%), particularly due to drug overdose. Controlling for socioeconomic factors, cocaine severity, and depression, the racial difference was still significant in the survival analysis. Racial differences were examined in the health status of those interviewed in the 12-year follow-up study (178 blacks and 65 whites), after confirmation of their comparable socioeconomic backgrounds and levels of healthcare access and utilization. Contrary to expectations, few racial differences were found on most health indicators, although the level of cocaine use was higher among blacks. Furthermore, fewer blacks reported having hepatitis or sexually transmitted diseases than did whites. The study results suggest that black cocaine-dependent veterans do not have worse health status when compared with white veterans on most health indicators.Yang, Huang, and Hser are with the UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.     

Emotional Distress and Mental Health Service Use Among Urban Homeless Adolescents

The Expanded Behavioral Model for Vulnerable Populations was used to examine the predisposing, enabling, and need factors associated with mental health service use in a homeless adolescent sample (N = 688). Among all youth, 32% perceived a need for help with mental health problems and 15% met Brief-Symptom Inventory (BSI) criteria for emotional distress. The rate of mental health service use in our sample was 32%. One enabling factor, having a case manager/discussed mental health concerns, and one need factor, which met criteria for BSI, were found to be associated with mental health service use in the past 3 months. The majority of youth who used mental health services had obtained services from crisis centers. Among those who perceived a need for help with mental health problems but who did not use services, the most common barrier was not knowing where to go or what service to use (57%). These findings suggest that due to the high prevalence of mental health problems among homeless youth, it would be helpful for service providers coming into contact with youth to make them aware of existing community resources for mental health services; making youth aware of these resources may in turn decrease the rate of crisis center use and instead allow youth to receive mental health services in outpatient settings that provide continuity of care.Research was conducted in collaboration with the David Geffen School of Medicine at University of California, Los Angeles, Department of Family Medicine (Dr. M.R. Solorio, Mr. S. Trifskin, and Dr. M.A. Rodríguez); NPI-Semel Institute for Neurosciences, Center for Community Health, University of California, Los Angeles (Dr. N.G. Milburn); and School of Public Health, Department of Health Services, University of California, Los Angeles (Dr. R.M. Andersen).     

Experiences of Social Stigma and Implications For Healthcare Among a Diverse Population of HIV Positive Adults

Stigma profoundly affects the lives of people with HIV/AIDS. Fear of being identified as having HIV or AIDS may discourage a person from getting tested, from accessing medical services and medications, and from disclosing their HIV status to family and friends. In the present study, we use focus groups to identify the most salient domains of stigma and the coping strategies that may be common to a group of diverse, low-income women and men living with HIV in Los Angeles, CA (n = 48). We also explore the impact of stigma on health and healthcare among HIV positive persons in our sample. Results indicate that the most salient domains of stigma include: blame and stereotypes of HIV, fear of contagion, disclosure of a stigmatized role, and renegotiating social contracts. We use the analysis to develop a framework where stigma is viewed as a social process composed of the struggle for both internal change (self-acceptance) and reintegration into the community. We discuss implications of HIV-related stigma for the mental and physical health of HIV-positive women and men and suggestions for possible interventions to address stigma in the healthcare setting. Sayles and Cunningham are with the Division of General Internal Medicine, University of California, Los Angeles, CA, USA; Ryan is with RAND Corporation, Santa Monica, CA, USA; Silver is with Fielding Graduate University, Santa Barbara, CA, USA; Sarkisian is with the Division of Geriatrics, University of California, Los Angeles, CA, USA; Cunningham is with UCLA School of Public Health, Los Angeles, CA, USA.     

Factors associated with success among southern Cheyenne and Arapaho Indians

Researchers in applied social science are seeking ways of approaching the facilitation of community-based development at the grass-roots level. Much research to date has focused on negative social aspects in communities, such as substance abuse and high numbers of school drop-outs. An innovative approach was developed that involved looking instead at successful individuals in communities. Individuals identified as successful were interviewed about the factors they associated with their own success. The experience of supportive parenting during their childhoods and moderation in alcohol and other substance use as adults were strongly correlated with success in life. The interview process provided an effective springboard for discussions and the development of intervention strategies at the community level.Alfred K. Neumann, M.A., M.D., M.P.H., is Professor in the Department of Community Health and Director of the Preventive Medicine Residency Program at the School of Public Health, University of California at Los Angeles. Velma Mason, Ph.D., is Special Assistant to the Director, Office of Indian Education, U.S. Department of Education, Washington, D.C. Emmett Chase, M.D., M.P.H., is National AIDS Coordinator of the Indian Health Service in Albuquerque, New Mexico, and was formerly Chief Physician of the American Indian Free Clinic in Compton, California, and Chief Resident of the UCLA Preventive Medicine Residency Program, School of Public Health at UCLA, Los Angeles. Bernard Albaugh, M.S.W., M.P.A., is Chairman of the Human Services Department, U.S. Public Health Service in Clinton, Oklahoma.The authors gratefully acknowledge the generous support of the UCLA Institute of American Cultures, the UCLA American Indian Studies Center, the New Era Foundation for International Development, the advice and encouragement of colleagues, and the Cheyenne/Arapaho Business Committee. Thanks also go to Ms. Melody Knutson and Ms. Julia George for their work in research and editing.     

Psychosocial problems in chronically ill children

This study concerns the psychosocial aspects of treatment for chronically ill children. The English-speaking parents of 44 children 5–13 years of age being seen at five specialty clinics at a large county hospital in Los Angeles, and their attending physicians, were the subjects in this study. The parents were interviewed concerning their expectations for the current visit, and the doctor-patient interaction was tape-recorded. Identical categories of information were abstracted from the tape recording and from a chart review of the patients' medical records. Although parents expected 76% of the psychosocial aspects of care to be covered by the doctor, only one fourth were actually discussed in the visit. These unfulfilled expectations were associated with lower satisfaction with medical care received (r=.47, p<0.01). Finally, while doctors recorded about 80% of discussions of symptoms and physical examinations in the patient's medical record, they recorded only 25% of discussion of psychosocial problems.Dr. Lau is Assistant Professor of Social Psychology, Carnegie-Mellon University, Pittsburgh, Pennsylvania. Dr. Williams is Assistant Clinical Professor of Pediatrics, University of South Dakota School of Medicine, Mitchell, South Dakota. Ms. Williams is with the University of California, Los Angeles. Dr. Ware is Senior Social Scientist, The Rand Corporation, Santa Monica, California. Dr. Brook is Professor of Medicine and Public Health, UCLA Center for the Health Sciences, Los Angeles. Preparation of this article was assisted by a grant from The Robert Wood Johnson Foundation, Princeton, New Jersey. The opinions, conclusions, and proposals in the text are those of the authors and do not necessarily represent the views of The Robert Wood Johnson foundation.     

Small Area Estimates Reveal High Cigarette Smoking Prevalence in Low-Income Cities of Los Angeles County

Los Angeles County has among the lowest smoking rates of large urban counties in the USA. Nevertheless, concerning disparities persist as high smoking prevalence is found among certain subgroups. We calculated adult smoking prevalence in the incorporated cities of Los Angeles County in order to identify cities with high smoking prevalence. The prevalence was estimated by a model-based small area estimation method with utilization of three data sources, including the 2007 Los Angeles County Health Survey, the 2000 Census, and the 2007 Los Angeles County Population Estimates and Projection System. Smoking prevalence varied considerably across cities, with a more than fourfold difference between the lowest (5.3%) and the highest prevalence (21.7%). Higher smoking prevalence was generally found in socioeconomically disadvantaged cities. The disparities identified here add another layer of data to our knowledge of the health inequities experienced by low-income urban communities and provide much sought data for local tobacco control. Our study also demonstrates the feasibility of providing credible local estimates of smoking prevalence using the model-based small area estimation method.     

Rodent Allergen in Los Angeles Inner City Homes of Children with Asthma

Recent studies have examined the presence of mouse allergen in inner city children with asthma. Researchers have found high levels of rodent allergen in homes sampled in the northeast and midwest United States, but there has been considerable variation between cities, and there have been few studies conducted in western states. We evaluated the frequency of rodent sightings and detectable mouse allergen and the housing conditions associated with these outcomes in inner city homes in Los Angeles. Two hundred and two families of school children, ages 6–16 living in inner city neighborhoods, participated in the study. Families were predominantly Latino (94%), and Spanish speaking (92%). At study entry, parents completed a home assessment questionnaire, and staff conducted a home evaluation and collected kitchen dust, which was analyzed for the presence of mouse allergen. Fifty-one percent of homes had detectable allergen in kitchen dust. All 33 families who reported the presence of rodents had detectable allergen in the home and were also more likely to have increased levels of allergen compared to those who did not report rodents. Unwashed dishes or food crumbs, lack of a working vacuum, and a caretaker report of a smoker in the home were all significantly associated with a greater risk of rodent sightings or detectable allergen (P < 0.05). Detached homes were significantly more likely to have detectable allergen. The prevalence of allergen is common enough that it may have public health implications for asthmatic children, and detectable allergen was not routinely identified based on rodent sightings. Many of the predictors of rodent allergen are amenable to low-cost interventions that can be integrated with other measures to reduce exposure to indoor allergens. Berg, Kotlerman, and Lewis are with the School of Nursing at the University of California, Los Angeles, Los Angeles, CA, USA; McConnell, Milam, Galvan, Jones, Ferdman, Peters, and Richardson are with the Departments of Preventive Medicine, Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA; Thorne is with the Department of Occupational and Environmental Health, University of Iowa, Iowa City, IA, USA; Eggleston and Rand are with the Departments of Medicine, Johns Hopkins University, Baltimore, MD, USA     

Child Sociodemographic Characteristics and Common Psychiatric Diagnoses in Medicaid Encounter Data: Are they Valid?

This study describes the rate that Medicaid encounter data on gender, race/ethnicity, and diagnosis matched information in the medical record, among a statewide sample of Medicaid children who received ongoing care for attention deficit hyperactivity disorder (ADHD), conduct disorder (CD), and major depression (MD) in outpatient specialty mental health clinics in 1998–1999. The match rate for gender was 99%; and for race/ethnicity it was 71.8%, 90.5%, and 89.7% for Caucasian, African American, and Hispanic children, respectively. Misidentified Caucasian children were more likely to be recorded as African American or Hispanic than misidentified minority children to be recorded as Caucasian. Diagnosis match rates were high (ADHD: 98%, CD: 89%, MD: 89%). If the California Department of Mental Health relied solely on Medicaid encounter data, misclassification of African American or Hispanic children as Caucasian could produce an underestimate of their service use.Michael S. Hurlburt, PhD, is a research scientist at Child and Adolescent Services Research Center, Children's Hospital, San Diego, 3020 Children's Way, San Diego, CA 92123-0282, USA.Eric C. Kostello, PhD, is a research sociologist at University of California at Los Angeles, Health Services Research Center, 10920 Wilshire Blvd., Suite 300, Los Angeles, CA 90024-6505, USA.Heather Ladd, MS, is a data analyst at University of California at Los Angeles, Health Services Research Center, 10920 Wilshire Blvd., Suite 300, Los Angeles, CA 90024-6505, USA.Lingqi Tang, PhD, is a statistician at University of California at Los Angeles, Health Services Research Center, 10920 Wilshire Blvd., Suite 300, Los Angeles, CA 90024-6505, USA.Bonnie T. Zima, MD, MPH, is a professor-in-residence of the Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, Health Services Research Center, 10920 Wilshire Blvd., Suite 300, Los Angeles, CA 90024-6505, USA.     

Determinants of dropout rate among hypertensive patients in an urban clinic

Noncompliance with follow-up is a serious problem in the management of hypertension. A retrospective cohort study examined dropout rates and their determinants among 249 randomly selected outpatients with essential hypertension from the medical clinic of an urban teaching hospital. Data were abstracted from hospital records and a subset of dropouts was interviewed. A lifetable analysis revealed that patients who were initiating therapy or who had been under therapy for less than six months had a 50% chance of remaining in care two years later, while 70% of patients who had been under therapy for more than six months at entry were still in care after this period. Patients who were less severely ill by several indicators were the most likely to drop out. It is hypothesized that the low perceived severity of illness, coupled with the costs and inconvenience of care and the lack of physician enthusiasm for the treatment of mild hypertension leads to noncompliance with follow-up.Dr. Gillum is with the Laboratory of Physiological Hygiene and the Department of Medicine, Schools of Public Health and Medicine, University of Minnesota, Minneapolis, Minnesota. Dr. Neutra is with the Division of Epidemiology of the School of Public Health, University of California at Los Angeles. Dr. Stason is with the Center for the Analysis of Health Practices at the Harvard School of Public Health, Boston, Massachusetts. Dr. Solomon is with the Department of Medicine at Peter Bent Brigham Hospital, Boston, Massachusetts. Reprint requests should be addressed to Dr. Gillum, Laboratory of Physiological Hygiene, University of Minnesota, Stadium Gate 27, 611 Beacon St. SE, Minneapolis, Minnesota 55455.     

The content of care provided by Family Nurse Practitioners

The content of care provided by 30 graduates of the UCLA Primex (Family Nurse Practitioner) program was examined. An encounter form similar to that used in the National Ambulatory Medical Care Survey was employed to code patients' complaints. These practitioners had been specifically trained to provide care for ambulatory patients. Data were collected one year after the completion of the university didactic phase of the program. We found that Primex practitioners spent more time with patients, more often employed traditional nursing functions, and more often used medical investigative procedures, such as x-rays and laboratory tests than did the physicians in the NAMC survey. Although the types of problems seen varied according to the organizational setting, these nurse practitioners were more often assigned routine health examinations and less often saw certain kinds of acute health care problems than had been anticipated in their training; 116 different types of symptoms or problems were presented, with a total of 1,170 encounters.The authors are with the UCLA Primex Program; Dr. Lewis is Professor of Medicine and Dr. Linn is Associate Researcher in the Department of Medicine, University of California at Los Angeles, Los Angeles, California 90024. This work was supported by grant HS-00985 from the National Center for Health Services Research.     

Building a respite for children and families.

The Los Angeles County-University of Southern California (LAC-USC) Medical Center is noted among the country's major metropolitan hospitals. Operated by the county of Los Angeles, this medical center ranks as the largest academic medical institution in the country with 2,045 licensed beds and an average daily census of 1,500. The sheer number of patients strain all available resources. Each year, more than 80,000 persons are admitted to the medical center and nearly 800,000 patients are seen in emergency and outpatient areas alone. While the medical center serves a county-wide and ethnically diverse population, it's also a crucial resource for the local community in East Los Angeles and downtown areas. Thousands of people from this community enter the hospital each day, either to receive treatment or to visit ill family members.     

Poverty, Wealth, and Health Care Utilization: A Geographic Assessment

Geographic variation has been of interest to both health planners and social epidemiologists. However, while the major focus of interest of planners has been on variation in health care spending, social epidemiologists have focused on health; and while social epidemiologists have observed strong associations between poor health and poverty, planners have concluded that income is not an important determinant of variation in spending. These different conclusions stem, at least in part, from differences in approach. Health planners have generally studied variation among large regions, such as states, counties, or hospital referral regions (HRRs), while epidemiologists have tended to study local areas, such as ZIP codes and census tracts. To better understand the basis for geographic variation in hospital utilization, we drew upon both approaches. Counties and HRRs were disaggregated into their constituent ZIP codes and census tracts and examined the interrelationships between income, disability, and hospital utilization that were examined at both the regional and local levels, using statistical and geomapping tools. Our studies centered on the Milwaukee and Los Angeles HRRs, where per capita health care utilization has been greater than elsewhere in their states. We compared Milwaukee to other HRRs in Wisconsin and Los Angeles to the other populous counties of California and to a region in California of comparable size and diversity, stretching from San Francisco to Sacramento (termed “San-Framento”). When studied at the ZIP code level, we found steep, curvilinear relationships between lower income and both increased hospital utilization and increasing percentages of individuals reporting disabilities. These associations were also evident on geomaps. They were strongest among populations of working-age adults but weaker among seniors, for whom income proved to be a poor proxy for poverty and whose residential locations deviated from the major underlying income patterns. Among working-age adults, virtually all of the excess utilization in Milwaukee was attributable to very high utilization in Milwaukee’s segregated “poverty corridor.” Similarly, the greater rate of hospital use in Los Angeles than in San-Framento could be explained by proportionately more low-income ZIP codes in Los Angeles and fewer in San-Framento. Indeed, when only high-income ZIP codes were assessed, there was little variation in hospital utilization among California’s 18 most populous counties. We estimated that had utilization within each region been at the rate of its high-income ZIP codes, overall utilization would have been 35 % less among working-age adults and 20 % less among seniors. These studies reveal the importance of disaggregating large geographic units into their constituent ZIP codes in order to understand variation in health care utilization among them. They demonstrate the strong association between low ZIP code income and both higher percentages of disability and greater hospital utilization. And they suggest that, given the large contribution of the poorest neighborhoods to aggregate utilization, it will be difficult to curb the growth of health care spending without addressing the underlying social determinants of health.     

Factors which influence use of prenatal care in low-income racialethnic women in Los Angeles county

There is very limited information on ethnic differences in use of prenatal care services. The purpose of this study was to examine the effect of sociodemographic, health behaviors, medical risk, and psychosocial risk factors on the timing of prenatal care among Black-American, Mexican-American, and recent Mexican immigrant women in Los Angeles. A sample of 107 primiparous women were interviewed using a structured questionnaire. Information obtained included socioeconomic indicators, relationship with baby's father, timing of prenatal care, psychosocial factors, and substance use before pregnancy. Ethnic patterns of timing of prenatal care revealed no significant differences. The relationship with the baby's father was associated with early timing of prenatal care and more prenatal care visits. Substance use before pregnancy was significantly related to total number of visits for this pregnancy.Ruth E. Zambrana is Associate Professor of Social Welfare; Christine Dunkel-Schetter is Associate Professor of Psychology; Susan Scrimshaw is Professor of Public Health and Anthropology; all at University of California, Los Angeles, 405 Hilgard Avenue, Los Angeles, California 90024.This study was supported by the following funding agencies: UCLA Center for the Study of Women, UCLA Biomedical Faculty Research Support Grant, UC Mexus Development (Grant DG87-123) and Agency for Health Care Policy and Research (formerly known as National Center for Health Services Research and Technology Assessment (HS/HD #05518-01A 1).     

Perceptions Towards Condom Use, Sexual Activity, and HIV Disclosure among HIV-Positive African American Men Who Have Sex with Men: Implications for Heterosexual Transmission

Disproportionately high HIV/AIDS rates and frequent non-gay identification (NGI) among African American men who have sex with men or with both men and women (MSM/W) highlight the importance of understanding how HIV-positive African American MSM/W perceive safer sex, experience living with HIV, and decide to disclose their HIV status. Thirty predominately seropositive and non-gay identifying African American MSM/W in Los Angeles participated in three semi-structured focus group interviews, and a constant comparison method was used to analyze responses regarding condom use, sexual activity after an HIV diagnosis, and HIV serostatus disclosure. Condom use themes included its protective role against disease and pregnancy, acceptability concerns pertaining to aesthetic factors and effectiveness, and situational influences such as exchange sex, substance use, and suspicions from female partners. Themes regarding the impact of HIV on sexual activity included rejection, decreased partner seeking, and isolation. Serostatus disclosure themes included disclosure to selective partners and personal responsibility. Comprehensive HIV risk-reduction strategies that build social support networks, condom self-efficacy, communication skills, and a sense of collective responsibility among NGI African American MSM/W while addressing HIV stigma in the African American community as a whole are suggested.Harawa is with the Charles B. Drew University of Medicine and Sciences, University of California, Los Angeles, CA, USA. Williams is with the Semel Institute of Neuroscience & Human Behavior, Suite C8-871C, 760 Westwood Plaza, Los Angeles, CA 90024-1759, USA. Williams and Ramamurthi are with the Department of Psychiatry & Biobehavioral Sciences, University of California, Los Angeles, CA, USA; Bingham is with the Los Angeles Department of Health Services, HIV Epidemiology Program, Los Angeles, CA, USA.     

Toward the Implementation of Mental Health Consumer Provider Services

Encouraged by the New Freedom Commission, mental health systems such as the Veteran Administration (VA) are now becoming more recovery-oriented. Consumer providers (CPs)—those with serious mental illness who are further along in recovery who provide services to others with similar mental health problems—are viewed as a key part of this change. However, organizational change theories suggest that careful consideration of implementation issues is critical when disseminating new and sometimes controversial services into existing organizations. Therefore, to guide the dissemination of CP services, the literature on the effectiveness of CPs was reviewed, and interviews, focus groups, and a brief survey of 110 administrators, providers, and patients were conducted at three large VA clinics in Southern California. Questions focused on their perceptions of feasibility and acceptability of CP services. Using literature and study findings, an organizational change framework and other strategies to overcome potential implementation challenges of CP services are suggested.Alexander S. Young, MD, MSHS, Director, Health Services Unit, VISN 22 MIRECC, West LA VA Healthcare Center, 11301 Wilshire Blvd., Los Angeles, CA 90073, USA.Joseph Hassell, MA, Program Coordinator, Health Services Unit, VISN 22 MIRECC, West LA VA Healthcare Center, 11301 Wilshire Blvd., Los Angeles, CA 90073, USA.Larry Davidson, PhD, Associate Professor and Director, Yale Program for Recovery and Community Health, Yale University School of Medicine, Department of Psychiatry, Erector Square 6W, Suite IC, 319, Peck Street, New Haven, CT 06511, USA.     

An assessment of the adequacy of self-care by adult asthmatics

Little is known about how individuals who have chronic disease actually manage their symptoms. This study involving a community-based population of 157 adult asthmatics assesses their ability to take care of their disease and to alter their behavior following a change in symptoms. Multiple techniques (interview, direct observation, and diary) were used to determine their behavior with respect to medications and physician use; these were then compared with criteria defining the requisite level of a behavior to reduce symptoms. Of the population assessed, 66% had no bronchodilator medication at home, 24% used an inhaler ineffectively, and 68% did not see a physician regularly. When faced with increasing symptoms, at least 40% of the asthmatics did not perform three basic and appropriate behaviors in medication use and physician contact. If physicians and other health care providers could decrease the frequency of these inappropriate self-care behaviors, it could result in improved health.From the UCLA Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, School of Medicine and School of Public Health, University of California, Los Angeles, California 90024. Preparation of this paper was assisted by a grant from the Robert Wood Johnson Foundation, Princeton, New Jersey. The opinions, conclusions, and proposals in the text are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation. Requests for reprints may be addressed to Robert H. Brook, M.D., The Rand Corporation, 1700 Main Street, Santa Monica, California 90406. The authors are indebted to Dr. Donald Tashkin for valuable assistance in reviewing the criteria used in this study to judge quality of care, to Dr. Roger Detels and Mrs. Anne Coulson whose UCLA Chronic Obstructive Respiratory Disease Study provided the study population, to Mrs. Xuan Le for diligent administrative assistance, and to Ms. Karen Kashiwagi for fine technical assistance.     

Some influences on public participation in a genetic screening program

To identify the psychosocial factors associated with voluntary cooperation in mass genetic testing, stratified random samples of 500 participants and 500 nonparticipants were drawn from an identified at-risk population for Tay-Sachs disease. Participants were relatively younger and better educated, reported higher levels of perceived susceptibility to being a carrier, and also stated more often that the impact of learning of being a carrier would be low. Participants were also more likely to indicate they would not alter plans for future progeny. Recommendations are made for enhancing participation in future genetic screening programs of this type.Dr. Becker is Associate Professor, Departments of Pediatrics (School of Medicine) and Behavioral Sciences (School of Hygiene and Public Health), The Johns Hopkins University, Edwards A. Park Building, Room B172, The Johns Hopkins Hospital, 601 North Broadway, Baltimore, Maryland 21205. Dr. Kaback is Associate Professor, Departments of Pediatrics and Medicine, and Associate Chief, Division of Medical Genetics, School of Medicine, University of California at Los Angeles. Dr. Rosenstock is Professor and Chairman, Department of Health Behavior, School of Public Health, University of Michigan. Ms. Ruth is Chairman, Department of Community Health Nursing, School of Nursing, University of Maryland.     

Associations between Methamphetamine Use and HIV among Men Who Have Sex with Men: A Model for Guiding Public Policy

Among men who have sex with men (MSM) in Los Angeles County, methamphetamine use is associated with high rates of HIV prevalence and sexual risk behaviors. In four separate samples of MSM who differed in the range of their intensity of methamphetamine use, from levels of recreational use to chronic use to those for MSM seeking drug abuse treatment, the association between methamphetamine use and HIV infection increased as the intensity of use increased. The lowest HIV prevalence rate (23%) was observed among MSM contacted through street outreach who mentioned recent methamphetamine use, followed by MSM who used at least once a month for six months (42%), followed by MSM seeking intensive outpatient treatment (61%). The highest rate (86%) was observed among MSM seeking residential treatment for methamphetamine dependence. The interleaving nature of these epidemics calls for comprehensive strategies that address methamphetamine use and concomitant sexual behaviors that increase risk of HIV transmission in this group already at high risk. These and other data suggest that MSM who infrequently use methamphetamine may respond to lower intensity/lower cost prevention and early intervention programs while those who use the drug at dependence levels may benefit from high intensity treatment to achieve goals of reduced drug use and HIV-risk sexual behaviors. Shoptaw is with the Department of Family Medicine, University of California, Los Angeles, CA, USA; Shoptaw and Reback are with the Integrated Substance Abuse Programs (ISAP), Los Angeles, CA, USA; Shoptaw and Reback are with the Friends Research Institute, Inc., Los Angeles, CA, USA; Shoptaw and Reback are with the Center for HIV Identification, Prevention and Treatment Services (CHIPTS), University of California, Los Angeles, CA, USA; Reback is with the Van Ness Recovery House, Los Angeles, CA, USA.