A potential role of anti-poverty programs in health promotion

Predictors of Viral Suppression Among People Living with HIV in Rural Oregon

With recent outbreaks of HIV in rural areas of the United States, it has become increasingly important to understand the factors affecting health outcomes of people with HIV living in rural areas. We assessed predictors of durable HIV viral suppression among rural participants using a pooled 7-year dataset from the Medical Monitoring Project (MMP), a cross-sectional, representative sample of individuals receiving HIV medical care in Oregon. Only 77.3% of rural participants achieved durable HIV viral suppression, while 22.7% had at least one detectable HIV viral load measurement within the past 12 months. The primary predictors of viral suppression were ARV adherence, poverty, and reported heavy drinking in the past 30 days. These results highlight the influence of social factors on health outcomes for persons with HIV living in rural areas and inform areas for policy and program change.

Behavior change, health, and health disparities 2023: Contingency management for treating substance use disorders and promoting health in vulnerable populations

This Special Issue (SI) of Preventive Medicine is the 10th in a series on behavior change, health, and health disparities. This issue focuses on Contingency Management (CM), a highly efficacious behavior-change intervention for substance use disorders (SUDs) and other behavioral health conditions wherein patients receive material incentives (e.g., vouchers exchangeable for retail items) contingent on objectively verified behavior change. Despite substantial support for its efficacy, CM remains largely unavailable in U.S. community SUD treatment facilities and other healthcare settings. This is especially concerning regarding stimulant use disorder for which CM is the only reliably efficacious intervention in controlled studies and yet is unavailable to the vast majority of those in need. This SI details recent promising developments in efforts to surmount longstanding implementation obstacles while also detailing other promising advances from meta-analyses and controlled trials examining CM's efficacy in treating other difficult-to-treat problems including smoking among pregnant women and mothers of young children as well among those as those experiencing homelessness and alcohol use disorder, the promise of digital CM, and a potential new application in promoting adherence with SUD medications.

Understanding why racial/ethnic inequities along the HIV care continuum persist in the United States: a qualitative exploration of systemic barriers from the perspectives of African American/Black and Latino persons living with HIV

BACKGROUND

Racial/ethnic inequities along the HIV care continuum persist in the United States despite substantial federal investment. Numerous studies highlight individual and social-level impediments in HIV, but fewer foreground systemic barriers. The present qualitative study sought to uncover and describe systemic barriers to the HIV care continuum from the perspectives of African American/Black and Latino persons living with HIV (PLWH) with unsuppressed HIV viral load, including how barriers operated and their effects.

METHODS

Participants were African American/Black and Latino PLWH with unsuppressed HIV viral load (N = 41). They were purposively sampled for maximum variability on key indices from a larger study. They engaged in semi-structured in-depth interviews that were audio-recorded and professionally transcribed. Data were analyzed using directed content analysis.

RESULTS

Participants were 49 years old, on average (SD = 9), 76% were assigned male sex at birth, 83% were African American/Black and 17% Latino, 34% were sexual minorities (i.e., non-heterosexual), and 22% were transgender/gender-nonbinary. All had indications of chronic poverty. Participants had been diagnosed with HIV 19 years prior to the study, on average (SD = 9). The majority (76%) had taken HIV medication in the six weeks before enrollment, but at levels insufficient to reach HIV viral suppression. Findings underscored a primary theme describing chronic poverty as a fundamental cause of poor engagement. Related subthemes were: negative aspects of congregate versus private housing settings (e.g., triggering substance use and social isolation); generally positive experiences with health care providers, although structural and cultural competency appeared insufficient and managing health care systems was difficult; pharmacies illegally purchased HIV medication from PLWH; and COVID-19 exacerbated barriers. Participants described mitigation strategies and evidenced resilience.

CONCLUSIONS

To reduce racial/ethnic inequities and end the HIV epidemic, it is necessary to understand African American/Black and Latino PLWH's perspectives on the systemic impediments they experience throughout the HIV care continuum. This study uncovers and describes a number of salient barriers and how they operate, including unexpected findings regarding drug diversion and negative aspects of congregate housing. There is growing awareness that systemic racism is a core determinant of systemic barriers to HIV care continuum engagement. Findings are interpreted in this context.

Early life stress, prenatal secondhand smoke exposure, and the development of internalizing symptoms across childhood

BACKGROUND

Prior findings relating secondhand tobacco smoke (SHS) exposure and internalizing problems, characterized by heightened anxiety and depression symptoms, have been equivocal; effects of SHS on neurodevelopment may depend on the presence of other neurotoxicants. Early life stress (ELS) is a known risk factor for internalizing symptoms and is also often concurrent with SHS exposure. To date the interactive effects of ELS and SHS on children's internalizing symptoms are unknown. We hypothesize that children with higher exposure to both prenatal SHS and ELS will have the most internalizing symptoms during the preschool period and the slowest reductions in symptoms over time.

METHODS

The present study leveraged a prospective, longitudinal birth cohort of 564 Black and Latinx mothers and their children, recruited between 1998 and 2006. Cotinine extracted from cord and maternal blood at birth served as a biomarker of prenatal SHS exposure. Parent-reported Child Behavior Checklist (CBCL) scores were examined at four timepoints between preschool and eleven years-old. ELS exposure was measured as a composite of six domains of maternal stress reported at child age five. Latent growth models examined associations between SHS, ELS, and their interaction term with trajectories of children's internalizing symptoms. In follow-up analyses, weighted quintile sum regression examined contributions of components of the ELS mixture to children's internalizing symptoms at each time point.

RESULTS

ELS interacted with SHS exposure such that higher levels of ELS and SHS exposure were associated with more internalizing symptoms during the preschool period (β = 0.14, p = 0.03). The interaction between ELS and SHS was also associated with a less negative rate of change in internalizing symptoms over time (β=-0.02, p = 0.01). Weighted quintile sum regression revealed significant contributions of maternal demoralization and other components of the stress mixture to children's internalizing problems at each age point (e.g., age 11 WQS β = 0.26, p < 0.01).

CONCLUSIONS

Our results suggest that prior inconsistencies in studies of SHS on behavior may derive from unmeasured factors that also influence behavior and co-occur with exposure, specifically maternal stress during children's early life. Findings point to modifiable targets for personalized prevention.

The association between probationers' addiction levels and socioeconomic-psychological characteristics

OBJECTIVE

The aim of this study is to evaluate probationers' addiction levels and associated socioeconomic and psychological features in Izmir Probation Directorate.

METHODS

This cross-sectional study was conducted in Izmir Probation Directorate between August 27, 2018 and November 27, 2018. The study's dependent variable was adult probationers' addiction level which was evaluated by the Addiction Profile Index-Clinical Version (API-C). The independent variables were individual factors, social environmental factors, API-C scale subdimensions and perceived social support. For paired comparisons, Student's t test and ANOVA were used. Linear regression analysis was used for multiple comparisons. p < 0.05 was accepted as the limit of statistical significance.

RESULTS

A total of 200 male probationers participated in the study (82.3%, n = 243). The participants' average age was 29.9 ± 7.7. The participants' average addiction score was 5.65 ± 2.33. According to the results of the regression analysis; education level (B = 1.438, 95% CI 0.936, 1.941, p < 0.001) working status at a job (B = 2.687, 95% CI 1.428, 3.945, p < 0.001) father's education level (B=-1.117, 95% CI -1.473, -0.762, p < 0.001) and anger management problems (B = 0.750, 95%CI 0.517, 0.982, p < 0.001) were explanatory for addiction level. The model was 50.8% explanatory of addiction level (p < 0.05).

CONCLUSION

Probationers who grew up with only their mother, whose father had a low education level, who had higher levels of anger management problems and who were unemployed had higher levels of addiction. These results emphasize the need for social work in the rehabilitation processes of individuals. Treating the risk factors indicated by the study results as screening and follow-up parameters in the probation population can be useful in improving the success of the probation program.

Measurement and identification of relative poverty level of pastoral areas: an analysis based on spatial layout

Pastoral areas are the key difficulty in China's pursuit of common prosperity and a key region for China to build the northern ecological safety barrier and to realize the Two Centenary Goals. It is of great significance to scientifically evaluate the quality of rural life (QRL), measure the relative poverty level (RPL), and identify the relatively poor areas, making it possible to dock poverty elimination with rural revitalization. Based on the socio-economic data of 18 pastoral areas in Inner Mongolia, this paper draws on spatial layout theory to evaluate QRL and measures RPL by the natural breakpoint method and then identifies the relatively poor areas in Inner Mongolia. The results show that (1) the QRLs of pastoral areas in Inner Mongolia were unbalanced and highly polarized. The mean score of QRLs was 0.2598. Eleven (61.11%) of the counties/banners had a QRL smaller than the mean score. On the spatial layout of QRLs, the western areas were stronger than the central areas. High QRL counties/banners are mainly concentrated in the western region. In the central region, the QRLs were very fragmented, falling onto all five levels. (2) The pastoral areas in Inner Mongolia differed significantly in RPL. The mean score of RPL stood at 0.3788. Nine counties/banners (50%) had an RPL greater than the mean. Contrary to the spatial layout features of QRLs, the central pastoral areas in Inner Mongolia had stronger RPLs than the eastern ones. High RPL counties/banners are mostly clustered in the central region. The spatial layout of RPLs is relatively reasonable in the central region: the RPLs decreased gradually from Dorbod Banner. (3) Nearly 45% of the pastoral areas in central and western Inner Mongolia face serious relative poverty and a high risk of returning to poverty. Eight counties/banners (45%) were identified as high composite relative poverty areas. From spatial layout, the composite relatively poor counties/banners clustered clearly, mainly in the western region. Finally, this paper establishes a warning mechanism against large-scale returning to poverty, aiming to lower composite RPL. The research results provide empirical reference and implementation path for consolidating the results of poverty eradication and facilitating rural revitalization.

The Effect of the "Triple-Layer Medical Security" Policy on the Vulnerability as Expected Poverty of Rural Households: Evidence from Yunnan Province, China

China launched the "critical battle against poverty" nationwide in 2012. As its main battlefield, Yunnan province promulgated the "triple medical security" (TMS) policy in 2017. This study, based on the pooled cross-section database of 2015-2020 of registered poor households in Yunnan province, employed the logit model to examine the effect of TMS on the vulnerability as expected poverty (VEP) of these households. It found that increasing the reimbursement rates for overall medical expenses and inpatient expenses and decreasing the proportion of out-of-pocket medical payment to income reduced the VEP; increases in the number of sick people in the family increased its VEP, and although the increase in the reimbursement rate for overall medical expenses or for inpatient expenses partially offset the VEP caused by the increase in the number of chronically ill people in the family, the VEP caused by the increase in the number of critically ill people would increase in the short term with the increase in the reimbursement rate for overall medical expenses or for inpatient expenses. The findings help improve policies concerning the medical security and health of the rural poor population, providing theoretical reference and practical guidance for future research.

Abstinence-contingent wage supplements to promote drug abstinence and employment: Post-intervention outcomes

BACKGROUND

Substance use disorder, unemployment, and poverty are interrelated problems that have not been addressed adequately by existing interventions. This study evaluated post-intervention effects of abstinence-contingent wage supplements on drug abstinence and employment.

METHODS

Unemployed adults enrolled in opioid agonist treatment were randomly assigned to an abstinence-contingent wage supplement group (n = 44) or a usual care control group (n = 47). All participants could work with an employment specialist throughout a 12-month intervention period. Those in the abstinence-contingent wage supplement group earned stipends for working with the employment specialist and, after gaining employment, abstinence-contingent wage supplements for working in their community job but had to provide opiate- and cocaine-negative urine samples to maximize pay. To assess post-intervention effects of abstinence-contingent wage supplements and compare those effects to during-intervention effects, we analyzed urine samples and self-reports every 3 months during the 12-month intervention and the 12-month post-intervention period.

RESULTS

During the intervention, abstinence-contingent wage supplement participants provided significantly more opiate- and cocaine-negative urine samples than usual care control participants; abstinence-contingent wage supplement participants were also significantly more likely to become employed and live out of poverty than usual care participants during intervention. During the post-intervention period, the abstinence-contingent wage supplement and usual care control groups had similar rates of drug abstinence, similar levels of employment, and similar proportions living out of poverty.

CONCLUSIONS

Long-term delivery of abstinence-contingent wage supplements can promote drug abstinence and employment, but many patients relapse to drug use and cease employment when wage supplements are discontinued.

Poverty Vulnerability and Health Risk Action Path of Families of Rural Elderly With Chronic Diseases: Empirical Analysis of 1,852 Families in Central and Western China

Health poverty has become the most important cause of poverty and return to poverty. Understanding the health risk factors and action paths of poverty in families of rural elderly with chronic diseases is important to alleviate return to poverty because of illness. This study selected families with at least one elderly member (over 60 years old) with chronic diseases (sample size was 1,852 families) in two provinces and four counties in central and western China. The three-stage feasible generalized least square method was adopted, and the appropriate poverty line standard was selected to measure the poverty vulnerability index. A poverty vulnerability index ≥50% was considered to indicate vulnerability. The poverty vulnerability index and actual income status were combined to classify the samples. A structural equation model was established to explore the path of each health risk factor on the entire sample and various types of poverty vulnerabilities. The mean poverty vulnerability of 1,852 families was 0.5974 ± 0.25213, and among which, 1,170 households had a poverty vulnerability value ≥0.5, accounting for 63.17% of the entire sample. The incidence of poverty was higher among people with low vulnerability to poverty. Health shock was the direct cause of poverty for people with potential and avoidance poverty. The mediating roles of family and community significantly differed in various types of poverty vulnerability. The social and economic environment in rural areas should be enhanced in a diversified manner, and the income-generating ability of rural households should be improved based on actual local conditions. Moreover, the prevention and control of poverty vulnerabilities should be diversified and targeted. Policies implemented should be based on people and localities, the causes of poverty and returning to poverty, and the types of poverty vulnerabilities. The use efficiency of medical insurance should be further improved, and the responsibility of medical insurance targeted poverty alleviation must be clarified.

Remotely administered incentive-based treatment for alcohol use disorder with participant-funded incentives is effective but less accessible to low-income participants

The delivery of monetary incentives contingent on verified abstinence is an effective treatment for alcohol use disorder. However, incentive cost has often been cited as a barrier to delivering this type of treatment. In the present randomized parallel groups trial, we systematically replicated a previous trial we conducted that employed remote alcohol monitoring and incentive delivery to promote abstinence from alcohol, but with the additional requirement for participants to partially self-fund their abstinence incentives. Treatment-seeking participants with alcohol use disorder (n = 92) who met inclusion criteria (n = 36) were randomized to either a Contingent or Noncontingent group (n = 18 each). Those not meeting inclusion criteria included 15 participants who agreed to the deposit requirement but failed to make the deposit payment. The Contingent group received nearly immediate monetary incentives each day they remotely provided negative breathalyzer samples. The Noncontingent group received matched incentives each day they successfully provided samples independent of alcohol content. Days abstinent in the Contingent group were 86%, which was significantly higher than the 44% recorded in the Noncontingent group, corresponding to an odds ratio of 8.2. Exploratory analyses revealed that the deposit requirement prevented participation in those with lower incomes and those with greater alcohol use. These results support the efficacy of this remotely deliverable alcohol abstinence reinforcement incentive intervention with a deposit requirement. However, the requirement to provide a monetary deposit to self-fund abstinence incentives may prevent those with greater alcohol use and/or those experiencing extreme poverty from participating in the intervention. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Evaluating an urban pediatric hospital's scald burn prevention program

BACKGROUND

Over 450,000 individuals are hospitalized with burns annually and roughly 35% are scald burns. Children younger than 5 years of age are at the greatest risk of scald burn injury. Caregiver burn prevention programs have been found to reduce the prevalence of injuries in young children; however, low-income and underserved populations seldomly have access to these programs. The impact of scald burn prevention programs in underserved populations remains unexplored. The objective of the current study was to evaluate the efficacy of a scald burn prevention program at a Level One Pediatric Trauma Center in a low-income, underserved community.

METHODS

Our hospital developed a one-hour scald burn prevention program for caregivers with children 5 years of age or younger. The program educated caregivers on ways to prevent scald burns and create safeguards in their home. Caregivers completed a pre-post survey to measure their ability to identify hot or cold objects, as well as respond to items about their perceptions of the program's utility, their willingness to share it with others, and the likelihood that they would use the information in the future. Data was analyzed using a paired t-test.

RESULTS

Two-hundred and sixty-nine (N = 269) caregivers participated in the program. Before the program, caregivers could identify potentially hot objects 83.17% of the time, and after the program, they were able to identify these items 92.31% of the time: t (268) = 12.46, p < .001, d = 1.07. Additionally, 95% of caregivers indicated that the program was helpful, 99% stated that they were likely to share this information with others, and 100% indicated that they would use the information from the program.

CONCLUSIONS

Education is a critical component to prevent scald burns. Results indicate that a hospital-led scald burn prevention program can positively impact a caregiver's ability to identify possible scald-burn risks. Providing education to caregivers who typically do not receive this information could lower the prevalence of scald burns not only institutionally, but in communities that are disproportionately impacted by this mechanism of injury.

Factors associated with obtaining employment among opioid use disorder patients enrolled in a therapeutic workplace intervention

BACKGROUND

Unemployment is a common problem among adults who have substance use disorder that often persists during treatment and recovery. We identified patient characteristics that were associated with obtaining employment among unemployed adults in opioid use disorder treatment.

METHODS

This analysis used data from participants (N = 91) who were enrolled in a randomized controlled trial evaluating the effectiveness of a therapeutic workplace in promoting drug abstinence and employment. After a 3-month training period (Phase 1), participants were randomly assigned to a study group and could work for 12 months with an employment specialist who assisted participants in obtaining employment (Phase 2). A logistic regression model was used to identify patient characteristics that were associated with obtaining employment.

RESULTS

Of the 91 participants, 39 (42.9 %) obtained employment. Compared to participants who did not obtain employment, participants who obtained employment worked more days in the therapeutic workplace during the training period (Phase 1) [OR (95 % CI) = 1.072 (1.015-1.132), p = .014], provided more opiate- and cocaine-negative urine samples while seeking employment [OR (95 % CI) = 1.015 (1.002-1.027), p = .025], and reported not usually being unemployed at study intake [OR (95 % CI) = 0.229 (0.080-0.652), p = .007].

CONCLUSIONS

Our analyses suggest that among unemployed adults in opioid use disorder treatment, those with the lowest rates of therapeutic workplace attendance, lowest rates of drug abstinence while seeking employment, and relatively long histories of unemployment are the least likely to obtain employment. These relations are potentially addressable at a practical level, and future research could build on these findings to improve the effectiveness of employment-based interventions.

Employment outcomes of substance use disorder patients enrolled in a therapeutic workplace intervention for drug abstinence and employment

Poverty is common among people who have substance use disorder. The therapeutic workplace addresses some of the interrelated and chronic problems of poverty, such as unemployment, lack of education and job skills, and drug use. A prior controlled trial showed that the therapeutic workplace was effective in promoting drug abstinence and self-reported community employment in unemployed adults in medication-assisted treatment for opioid use disorder. The current study extends this research by providing a detailed and objective analysis of employment outcomes using objective data abstracted from participants' pay stubs. Secondary analyses examined the types and patterns of employment that participants (N = 44) obtained during the trial, and the extent to which participants gained and maintained financially sufficient employment. Although most participants had relatively long histories of unemployment and underemployment, many participants (n = 26; 59%) obtained employment at some point during the intervention. Most participants worked part time and were employed in low-wage jobs, however. The mean number of hours worked per week was 20.6 h (range 5.5 to 41.3 h per week) and the mean hourly pay was $11.00 per hour (range $9.00 to $15.50 per hour). The most common type of employment was in food preparation and serving-related occupations (e.g., waiters and waitresses, restaurant cooks, and fast food counter workers). Many participants (n = 17; 65%) maintained employment in these jobs over several weeks, while others (n = 9; 35%) were employed sporadically for short durations. Additional supports may be needed for some chronically unemployed adults with substance use disorder to promote consistent employment in well-paying jobs.

Financial incentives promote engagement in employment services for unemployed adults in treatment for opioid use disorder

BACKGROUND

Promoting employment among unemployed adults with substance use disorder is a difficult challenge for which existing interventions have had limited effects. This study examined whether financial incentives could increase engagement in employment services for unemployed adults in treatment for opioid use disorder.

METHODS

The study was conducted from 2014 to 2019 in Baltimore, MD. After a 3-month abstinence initiation and training period, participants (N = 91) were randomly assigned to a Control group or an Incentive group and were invited to work with an employment specialist to seek employment in a community job for 12 months. Participants assigned to the Control group (n = 47) did not receive incentives for working with the employment specialist. Participants assigned to the Incentive group (n = 44) could earn financial incentives for working with the employment specialist, but had to provide opiate- and cocaine-negative urine samples to maximize pay.

RESULTS

Incentive participants attended the employment services and worked with the employment specialist on significantly more days than Control participants (41.8 % versus 1.1 % of days; OR = 40.42, 95 % CI = 32.46-48.38, p < .001), and for significantly more hours than Control participants (3.58 versus 1.25 h, on average; OR=2.34, 95 % CI=1.83-2.85, p < .001). Incentive participants were more likely to be retained than Control participants when analyses were based solely on attendance (HR=0.12, 95 % CI=0.06-0.25, p < .001) and attendance and employment combined (HR=0.15, 95 % CI=0.07-0.31, p < .001).

CONCLUSIONS

Financial incentives were effective in promoting engagement in employment services for individuals who often do not utilize employment services.

Abstinence-contingent wage supplements to promote drug abstinence and employment: a randomised controlled trial

BACKGROUND

Poverty, unemployment and substance abuse are inter-related problems. This study evaluated the effectiveness of abstinence-contingent wage supplements in promoting drug abstinence and employment in unemployed adults in outpatient treatment for opioid use disorder.

METHODS

A randomised controlled trial was conducted in Baltimore, MD, from 2014 to 2019. After a 3-month abstinence initiation and training period, participants (n=91) were randomly assigned to a usual care control group that received employment services or to an abstinence-contingent wage supplement group that received employment services plus abstinence-contingent wage supplements. All participants were invited to work with an employment specialist to seek employment in a community job for 12 months. Abstinence-contingent wage supplement participants could earn training stipends for working with the employment specialist and wage supplements for working in a community job, but had to provide opiate and cocaine-negative urine samples to maximise pay.

RESULTS

Abstinence-contingent wage supplement participants provided significantly more opiate and cocaine-negative urine samples than usual care control participants (65% vs 45%; OR=2.29, 95% CI 1.22 to 4.30, p=0.01) during the 12-month intervention. Abstinence-contingent wage supplement participants were significantly more likely to have obtained employment (59% vs 28%; OR=3.88, 95% CI 1.60 to 9.41, p=0.004) and lived out of poverty (61% vs 30%; OR=3.77, 95% CI 1.57 to 9.04, p=0.004) by the end of the 12-month intervention than usual care control participants.

CONCLUSION

Abstinence-contingent wage supplements can promote drug abstinence and employment.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT02487745.

The Utility of Operant Conditioning to Address Poverty and Drug Addiction

Poverty is associated with poor health. This article reviews research on proximal and distal operant interventions to address drug addiction and poverty. Proximal interventions promote health behaviors directly. Abstinence reinforcement, a common proximal intervention for the treatment of drug addiction, can be effective. Manipulating familiar parameters of operant conditioning can improve the effectiveness of abstinence reinforcement. Increasing reinforcement magnitude can increase the proportion of individuals that respond to abstinence reinforcement, arranging long-term exposure to abstinence reinforcement can prevent relapse, and arranging abstinence reinforcement sequentially across drugs can promote abstinence from multiple drugs. Distal interventions reduce risk factors that underlie poor health and may have an indirect beneficial effect on health. In the case of poverty, distal interventions seek to move people out of poverty. The therapeutic workplace includes both proximal and distal interventions to treat drug addiction and poverty. In the therapeutic workplace, participants earn stipends or wages to work. The therapeutic workplace uses employment-based reinforcement in which participants are required to provide drug-free urine samples or take scheduled doses of addiction medications to work and/or maintain maximum pay. The therapeutic workplace has two phases, a training and an employment phase. Special contingencies appear required to promote skill development during the training phase, employment-based reinforcement can promote abstinence from heroin and cocaine and adherence to naltrexone, and the therapeutic workplace can increase employment. Behavior analysts are well-suited to address both poverty and drug addiction using operant interventions like the therapeutic workplace.

Generalized anxiety disorder symptoms among persons with diagnosed HIV in the United States

OBJECTIVE

To estimate the prevalence of generalized anxiety disorder (GAD) symptoms among adults with diagnosed HIV (PWH) in the United States in order to inform effective HIV prevention and care efforts.

DESIGN

The Medical Monitoring Project (MMP) is a complex sample survey of adults with diagnosed HIV in the United States.

METHODS

We used MMP data collected during June 2015 to May 2016 to calculate the weighted prevalence of GAD symptoms among PWH (N = 3654) and prevalence ratios with predicted marginal means to evaluate significant differences between groups.

RESULTS

The estimated prevalence of GAD symptoms among PWH was 19%. GAD symptoms were associated with significantly lower antiretroviral therapy prescription and adherence, medical HIV care engagement, and sustained viral suppression. Persons with GAD symptoms were over three times as likely to have an unmet need for mental health services (23 vs. 7%) and had significantly more emergency room visits and hospitalizations than those without these symptoms. GAD symptoms were associated with significantly higher prevalence of condomless sex while not sustainably virally suppressed with a person not known to be taking preexposure prophylaxis (9 vs. 6%).

CONCLUSION

GAD symptom prevalence among PWH was considerably higher than among the US general adult population, indicating an excess burden of anxiety among PWH. Outcomes along the HIV care continuum were poorer, and risk for HIV transmission was higher, among persons with symptoms. Incorporating routine screening for GAD in HIV clinical settings may help improve health outcomes, reduce HIV transmission, and save healthcare costs.

Behavior analysts in the war on poverty: Developing an operant antipoverty program

Poverty is associated with poor health and affects many United States residents. The therapeutic workplace, an operant intervention designed to treat unemployed adults with histories of drug addiction, could form the basis for an effective antipoverty program. Under the therapeutic workplace, participants receive pay for work. To promote drug abstinence or medication adherence, participants must provide drug-free urine samples or take scheduled doses of medication, respectively, to maintain maximum pay. Therapeutic workplace participants receive job-skills training in Phase 1 and perform income-producing jobs in Phase 2. Many unemployed, drug-addicted adults lack skills they would need to obtain high-skilled and high-paying jobs. Many of these individuals attend therapeutic workplace training reliably, but only when offered stipends for attendance. They also work on training programs reliably, but only when they earn stipends for performance on training programs. A therapeutic workplace social business can promote employment, although special contingencies may be needed to ensure that participants are punctual and work entire work shifts, and social businesses do not reliably promote community employment. Therapeutic workplace participants work with an employment specialist to seek community employment, but primarily when they earn financial incentives. Reducing poverty is more challenging than promoting employment, because it requires promoting employment in higher paying, full-time and steady jobs. Although a daunting challenge, promoting the type of employment needed to reduce poverty is an important goal, both because of the obvious benefit in reducing poverty itself and in the potential secondary benefit of reducing poverty-related health disparities. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Behavior analysts in the war on poverty: A review of the use of financial incentives to promote education and employment

Poverty is a pervasive risk factor underlying poor health. Many interventions that have sought to reduce health disparities associated with poverty have focused on improving health-related behaviors of low-income adults. Poverty itself could be targeted to improve health, but this approach would require programs that can consistently move poor individuals out of poverty. Governments and other organizations in the United States have tested a diverse range of antipoverty programs, generally on a large scale and in conjunction with welfare reform initiatives. This paper reviews antipoverty programs that used financial incentives to promote education and employment among welfare recipients and other low-income adults. The incentive-based, antipoverty programs had small or no effects on the target behaviors; they were implemented on large scales from the outset, without systematic development and evaluation of their components; and they did not apply principles of operant conditioning that have been shown to determine the effectiveness of incentive or reinforcement interventions. By applying basic principles of operant conditioning, behavior analysts could help address poverty and improve health through development of effective antipoverty programs. This paper describes a potential framework for a behavior-analytic antipoverty program, with the goal of illustrating that behavior analysts could be uniquely suited to make substantial contributions to the war on poverty.

Editorial: 3rd Special Issue on behavior change, health, and health disparities

This Special Issue of Preventive Medicine (PM) is the 3rd that we have organized on behavior change, health, and health disparities. This is a topic of critical importance to improving U.S. population health. There is broad scientific consensus that personal behaviors such as cigarette smoking, other substance abuse, and physical inactivity/obesity are among the most important modifiable causes of chronic disease and its adverse impacts on population health. Hence, effectively promoting health-related behavior change needs to be a key component of health care research and policy. There is also broad recognition that while these problems extend throughout the population, they disproportionately impact economically disadvantaged populations and other vulnerable populations and represent a major contributor to health disparities. Thus, behavior change represents an essential step in curtailing health disparities, which receives special attention in this 3rd Special Issue. We also devote considerable space to the longstanding challenges of reducing cigarette smoking and use of other tobacco and nicotine delivery products in vulnerable populations, obesity, and for the first time food insecurity. Across each of these topics we include contributions from highly accomplished policymakers and scientists to acquaint readers with recent accomplishments as well as remaining knowledge gaps and challenges.