Experiences With Food Insecurity and Risky Sex Among Low-Income People Living With HIV/AIDS in a Resource-Rich Setting

Background: Forty-nine million individuals are food insecure in the United States, where food insecurity and HIV/AIDS are prevalent among the urban poor. Food insecurity is associated with risky sexual behaviours among people living with HIV/AIDS (PLHIV). No qualitative studies, however, have investigated the mechanisms underlying this relationship either in a resource-rich setting or among populations that include men who have sex with men (MSM). Methods: Semi-structured in-depth interviews were conducted with 34 low-income PLHIV receiving food assistance in the San Francisco Bay Area. The interviews explored experiences with food insecurity and perceived associations with sexual risk behaviours. Interviews were conducted in English, audio-recorded and transcribed verbatim. Transcripts were coded and analyzed according to content analysis methods using an inductive-deductive approach. Results: Food insecurity was reported to be a strong contributor to risky sexual practices among MSM and female participants. Individuals described engaging in transactional sex for food or money to buy food, often during times of destitution. Participants also explained how food insecurity could lead to condomless sex despite knowledge of and desire to use safe sexual practices, largely because the need to obtain food in the short term was prioritized over the desire to use barrier protection. Conclusions: Our data extend previous research by demonstrating that food insecurity contributes to transactional and unprotected sex among urban poor individuals in a resource-rich setting, including among MSM. These findings underscore the importance of public health and social intervention efforts focused on structural inequalities

Assessing Patient Activation among High-Need, High-Cost Patients in Urban Safety Net Care Settings.

We sought to examine the literature using the Patient Activation Measure (PAM) or the Patient Enablement Instrument (PEI) with high-need, high-cost (HNHC) patients receiving care in urban safety net settings. Urban safety net care management programs serve low-income, racially/ethnically diverse patients living with multiple chronic conditions. Although many care management programs track patient progress with the PAM or the PEI, it is not clear whether the PAM or the PEI is an effective and appropriate tool for HNHC patients receiving care in urban safety net settings in the United States. We searched PubMed, EMBASE, Web of Science, and PsycINFO for articles published between 2004 and 2015 that used the PAM and between 1998 and 2015 that used the PEI. The search was limited to English-language articles conducted in the United States and published in peer-reviewed journals. To assess the utility of the PAM and the PEI in urban safety net care settings, we defined a HNHC patient sample as racially/ethnically diverse, low socioeconomic status (SES), and multimorbid. One hundred fourteen articles used the PAM. All articles using the PEI were conducted outside the U.S. and therefore were excluded. Nine PAM studies (8%) included participants similar to those receiving care in urban safety net settings, three of which were longitudinal. Two of the three longitudinal studies reported positive changes following interventions. Our results indicate that research on patient activation is not commonly conducted on racially and ethnically diverse, low SES, and multimorbid patients; therefore, there are few opportunities to assess the appropriateness of the PAM in such populations. Investigators expressed concerns with the potential unreliability and inappropriate nature of the PAM on multimorbid, older, and low-literacy patients. Thus, the PAM may not be able to accurately assess patient progress among HNHC patients receiving care in urban safety net settings. Assessing progress in the urban safety net care setting requires measures that account for the social and structural challenges and competing demands of HNHC patients

Social Literacy: Nurses' Contribution Toward the Co-Production of Self-Management.

We share findings from a larger ethnographic study of two urban complex care management programs in the Western United States. The data presented stem from in-depth interviews conducted with 17 complex care management RNs and participant observations of home visits. We advance the concept of social literacy as a nursing attribute that comprises an RN's recognition and responses to the varied types of hinderances to self-management with which patients must contend in their lived environment. It is through social literacy that complex care management RNs reconceptualize and understand health literacy to be a product born out of the social circumstances in which patients live and the stratified nature of the health care systems that provide them care. Social literacy provides a broader framework for health literacy-one that is situated within the patient's social context through which complex care management RNs must navigate for self-management goals to be achieved

Survivorship Care Plan Information Needs: Perspectives of Safety-Net Breast Cancer Patients.

PurposeDespite the Institute of Medicine's (IOM) 2005 recommendation, few care organizations have instituted standard survivorship care plans (SCPs). Low health literacy and low English proficiency are important factors to consider in SCP development. Our study aimed to identify information needs and survivorship care plan preferences of low literacy, multi-lingual patients to support the transition from oncology to primary care and ongoing learning in survivorship.MethodsWe conducted focus groups in five languages with African American, Latina, Russian, Filipina, White, and Chinese medically underserved breast cancer patients. Topics explored included the transition to primary care, access to information, knowledge of treatment history, and perspectives on SCPs.ResultsAnalysis of focus group data identified three themes: 1) the need for information and education on the transition between "active treatment" and "survivorship"; 2) information needed (and often not obtained) from providers; and 3) perspectives on SCP content and delivery.ConclusionsOur data point to the need to develop a process as well as written information for medically underserved breast cancer patients. An SCP document will not replace direct communication with providers about treatment, symptom management and transition, a communication that is missing in participating safety-net patients' experiences of cancer care. Women turned to peer support and community-based organizations in the absence of information from providers.Implications for cancer survivors"Clear and effective" communication of survivorship care for safety-net patients requires dedicated staff trained to address wide-ranging information needs and uncertainties

Social Literacy: Nurses' Contribution Toward the Co-Production of Self-Management.

We share findings from a larger ethnographic study of two urban complex care management programs in the Western United States. The data presented stem from in-depth interviews conducted with 17 complex care management RNs and participant observations of home visits. We advance the concept of social literacy as a nursing attribute that comprises an RN's recognition and responses to the varied types of hinderances to self-management with which patients must contend in their lived environment. It is through social literacy that complex care management RNs reconceptualize and understand health literacy to be a product born out of the social circumstances in which patients live and the stratified nature of the health care systems that provide them care. Social literacy provides a broader framework for health literacy-one that is situated within the patient's social context through which complex care management RNs must navigate for self-management goals to be achieved

Survivorship Care Plan Information Needs: Perspectives of Safety-Net Breast Cancer Patients.

PurposeDespite the Institute of Medicine's (IOM) 2005 recommendation, few care organizations have instituted standard survivorship care plans (SCPs). Low health literacy and low English proficiency are important factors to consider in SCP development. Our study aimed to identify information needs and survivorship care plan preferences of low literacy, multi-lingual patients to support the transition from oncology to primary care and ongoing learning in survivorship.MethodsWe conducted focus groups in five languages with African American, Latina, Russian, Filipina, White, and Chinese medically underserved breast cancer patients. Topics explored included the transition to primary care, access to information, knowledge of treatment history, and perspectives on SCPs.ResultsAnalysis of focus group data identified three themes: 1) the need for information and education on the transition between "active treatment" and "survivorship"; 2) information needed (and often not obtained) from providers; and 3) perspectives on SCP content and delivery.ConclusionsOur data point to the need to develop a process as well as written information for medically underserved breast cancer patients. An SCP document will not replace direct communication with providers about treatment, symptom management and transition, a communication that is missing in participating safety-net patients' experiences of cancer care. Women turned to peer support and community-based organizations in the absence of information from providers.Implications for cancer survivors"Clear and effective" communication of survivorship care for safety-net patients requires dedicated staff trained to address wide-ranging information needs and uncertainties

Direct-acting antiviral treatment for HIV/HCV patients in safety net settings: patient and provider preferences.

HIV/HCV coinfected patients are a priority for direct acting antiretroviral (DAA) treatment, yet barriers to treating vulnerable patients persist. This study surveyed safety net clinic patients and providers to quantify their preferences for DAA treatment and prioritize modifiable barriers. Preferences were assessed using best-worst scaling. General linear mixed models were used to determine whether attributes differed in importance and whether patients and providers valued attributes differently. 158 HIV/HCV coinfected patients and 49 providers participated. Patients and providers had strong preferences for treatment within the medical homes where patients receive HIV care. Support such as reminders and advice numbers were also important, but were more important to providers than patients. Providers identified lack of insurance coverage for DAA as the most significant barrier. Providers rated HIV primary care providers as best suited to deliver DAA to HIV+ patients. Addressing structural barriers is essential for increasing DAA treatment in safety net settings

Direct-acting antiviral treatment for HIV/HCV patients in safety net settings: patient and provider preferences.

HIV/HCV coinfected patients are a priority for direct acting antiretroviral (DAA) treatment, yet barriers to treating vulnerable patients persist. This study surveyed safety net clinic patients and providers to quantify their preferences for DAA treatment and prioritize modifiable barriers. Preferences were assessed using best-worst scaling. General linear mixed models were used to determine whether attributes differed in importance and whether patients and providers valued attributes differently. 158 HIV/HCV coinfected patients and 49 providers participated. Patients and providers had strong preferences for treatment within the medical homes where patients receive HIV care. Support such as reminders and advice numbers were also important, but were more important to providers than patients. Providers identified lack of insurance coverage for DAA as the most significant barrier. Providers rated HIV primary care providers as best suited to deliver DAA to HIV+ patients. Addressing structural barriers is essential for increasing DAA treatment in safety net settings