Andersen's Revised Behavioral Model of Health Services Use (RBM) was used as a framework in this correlational cross-sectional study to examine factors associated with HIV testing among a sample of 251 rural African American cocaine users. All participants reported using cocaine and being sexually active within the past 30 days. Independent variables were categorized according to the RBM as predisposing, enabling, need, or health behavior factors. Number of times tested for HIV (never, one time, two to four times, five or more times) was the outcome of interest. In ordered logistic regression analyses, HIV testing was strongly associated with being female, of younger age (predisposing factors); having been tested for sexually transmitted diseases or hepatitis, ever having been incarcerated in jail or prison (enabling factors); and having had one sex partner the past 30 days (health behavior factor). Other sexual risk behaviors, drug use, health status, and perception of risk were not associated with HIV testing. Our findings confirm the importance of routine testing in all healthcare settings rather than risk-based testing.
Although previous research has described a high prevalence of psychiatric comorbidity among general medical and surgical patients, prevalence estimates based on diagnostic criteria and the assessment of health care outcomes including functional status has not been conducted for a broad range of psychiatric disorders.
Methods
A random sample of male medical and surgical admissions to 3 Department of Veterans Affairs Medical Centers was enrolled in the study. Subjects were administered a computerized structured psychiatric diagnostic interview and completed a multidimensional measure of health-related functioning, the Medical Outcomes Study 36-Item Short-Form Health Survey.
Results
Of 1007 medical and surgical inpatients, almost half (46.6%) met lifetime criteria for at least 1Diagnostic and Statistical Manual of Mental Disorders, Revised Third Editiondisorder, most commonly for alcohol abuse or dependence (32.5%), posttraumatic stress disorder (10.0%), and major depression or dysthymia (9.0%). Almost one fifth reported recent symptoms, most frequently for major depression or dysthymia (7.0%). Co-occurring psychiatric disorders were associated with substantial and significant (P<.001) impairment on all dimensions of functioning, with the greatest decrements observed in physical and emotional role functioning. Anxiety and mood disorders were associated with the most and somewhat similar reductions in functioning.
Conclusions
The prevalence of co-occurring psychiatric disorders was substantial but consistent with other studies of populations receiving health services. Given the observed additional burden of psychiatric disorders on functioning in medically hospitalized patients, the study indicates the importance of identification and treatment of co-occurring psychiatric disorders in this high-risk and clinically challenging group of patients.
Substance abuse is a chronic, relapsing condition, yet some individuals over time seem to cease use for factors that are largely unclear. A life threatening episode of cocaine-associated chest pain requiring an emergency department (ED) visit may influence subsequent use. A consecutive cohort (n = 219) of patients who presented to a large, urban ED with cocaine-associated chest pain was interviewed at baseline, three months, six months, and 12 months to evaluate longitudinal rates of subsequent drug use. Overall, there was a significant decrease in cocaine use over time (baseline = 100.0%, three months = 56.5%, six months = 54.2%, and 12 months = 51.7%, p < .05 for baseline versus each follow-up interval). Findings suggest that substance use declines following an ED visit for cocaine-related chest pain. However, about half of the subjects were still using cocaine one year later. Future studies examining the potential impact of brief interventions or case management to intervene with this not-in-treatment ED population are warranted.
From 1995 to 2000 the Department of Veterans Affairs (VA) dramatically reduced addiction treatment funding and regionalized specialized services to urban centers. By using New York State as an example, this study examined whether regionalization disproportionately affected rural versus urban veterans' use of VA and non-VA inpatient addiction services.By using a comprehensive data set of VA and non-VA hospitalizations for 294,748 VA enrollees who were residents of New York State from 1998 to 2000, this study examined admission rates for addiction treatment to VA and non-VA centers to determine how rates differed between rural veterans and urban veterans.Between 1998 and 2000 rural veterans obtained 67% of their inpatient addiction care from the VA, compared with 54% for urban veterans (p<.001). Compared with 1998 levels, the odds ratios of admission to VA facilities for inpatient detoxification fell for both rural and urban veterans to .80 in 1999 and .65 in 2000 (both p<.05). Although odds ratios of non-VA inpatient admission for addiction treatment were stable over time for urban veterans, those for rural veterans fell from 1998 values, falling to .76 in 1999 (not significant) and .62 in 2000 (p<.001) for detoxification and to .66 in 1999 (not significant) and .51 in 2000 for rehabilitation (p<.05). Odds ratios for urban veterans' admission to VA facilities for rehabilitation fell to .51 in terms of 1998 rates in 1999 and .38 in 2000, but rural veterans' odds ratios fell more, to .31 and .16, respectively (p<.001 for all).In New York regionalization of VA addiction services disproportionately affected rural veterans. Rural veterans experienced concurrent reductions in VA and non-VA inpatient addiction services. The VA and other health care policy makers should consider the potential unintended consequences to rural populations of resource reallocation.
Abstract Purpose Integrating HIV testing programs into substance use treatment is a promising avenue to help increase access to HIV testing for rural drug users. Yet few outpatient substance abuse treatment facilities in the United States provide HIV testing. The purpose of this study was to identify barriers to incorporating HIV testing with substance use treatment from the perspectives of treatment and testing providers in Arkansas. Methods We used purposive sampling from state directories to recruit providers at state, organization, and individual levels to participate in this exploratory study. Using an interview guide, the first and second authors conducted semistructured individual interviews in each provider's office or by telephone. All interviews were recorded, transcribed verbatim, and entered into ATLAS.ti software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). We used constant comparison and content analysis techniques to identify codes, categories, and primary patterns in the data. Findings The sample consisted of 28 providers throughout the state, 18 from the substance use system and 10 from the public/ community health system. We identified 7 categories of barriers: environmental constraints, policy constraints, funding constraints, organizational structure, limited inter‐ and intra‐agency communication, burden of responsibility, and client fragility. Conclusions This study presents the practice‐based realities of barriers to integrating HIV testing with substance use treatment in a small, largely rural state. Some system and/or organization leaders were either unaware of or not actively pursuing external funds available to them specifically for engaging substance users in HIV testing. However, funding does not address the system‐level need for coordination of resources and services at the state level.
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