Transcript Hepatitis C Prevalence Among Homeless Women and Their

A Randomized Controlled Trial of
Two Treatment Programs for
Homeless Adults with Latent
Tuberculosis Infection
Adeline Nyamathi, ANP, PhD, FAAN
Audrienne H. Moseley Endowed Chair
in Community Health Research
Professor and Dean for Academic Affairs
UCLA School of Nursing
Problem
TB – Homeless at higher risk
• Compromised immune system from drug
use, overcrowding; and poor nutrition
• Little access to health and social services
• Poor adherence to preventive health
• LTBI treatment shown to reduce risk of
progression to active TB by 64% to 93% (ATS,
2000)
• LTBI completion rates among the homeless
have ranged from 19% to 44% (Tulsky et al., 2000)
Specific Aims
To compare the effectiveness of a
theoretically-based comprehensive
intervention program employing nurse
case management against a control
program with standard care on LTBI
treatment completion in a homeless
population.
Study Design
• Prospective, two-group, site randomized
design
• Age 18-55, or over 55 with reported risk
activation factors for TB
• Homeless the previous night
• Denied previous LTBI treatment
Positive TB Skin Test
• Induration > 10 mm in HIV seronegative
individuals
• Induration > 5 mm in HIV seropositive
individuals
Comprehensive Health
Seeking and Coping
Paradigm
(Nyamathi, 1989)
Intervention - 1
NCMI: The intervention components,
delivered in a culturally competent and
tailored manner by assigned nurses and
outreach workers during five weekly
sessions include:
1) TB and HIV risk reduction education;
2) Social and cognitive problem-solving
training pertinent to the implementation of
behavior change
Intervention - 2
NCMI (continued):
3) Training in behavioral, selfmanagement,and communications skill
competencies necessary for risk reduction
change for TB and HIV;
4) Development of relationships, activities
and social networks conducive to
maintaining reductions in risk behavior;
5) Administer DOT biweekly for 52 doses;
6) Provide a $5 incentive
Intervention - 3
Traditional Program: Interact
biweekly with the UCLA research
nurse and outreach workers
stationed at the Satellite Clinic who:
1) Provide a 20-minute education
program;
2) administer DOT biweekly x 52
doses; and
3) Provide a $5 incentive
Assessments
• TB completion by logs
• Drug and Alcohol Use by TCU Drug History
Form (Simpson & Chatam, 1995)
• Social Support- 18 item RAND Medical
Outcomes Study (Sherbourne & Stewart,
1991) (Cronbach’s alpha .91-97)
• Depressive Symptoms (CES-D)
(Radloff, 1977)
• Psychological Well-Being RAND Mental
Health
• Baseline and Six-Month
Follow-up
• 98%
• Importance of Tracking
Assumptions
• Participant’s confidentiality is ALWAYS kept
• Use of locator guide
• Approved photo
• Check prison and jail rosters
• Participant’s specific requests about who to
contact & who NOT to contact are ALWAYS
honored
Persistence!
• Tracking, locating, and eventually
completing a follow-up interview is ALL
about persistence
• Track daily, track often
• Always assume that you WILL find the
person
• And NEVER give up!
Results
• Using intent to treat analysis, 62% of
intervention participants completed 6
months of LTBI treatment with INH,
compared to 39% of controls.
Sociodemographics
Characteristics by Group
•
•
•
•
NCMI (n = 283) Traditional (n = 237)
Average age 41.5 years
Mean education 12 years
Gender*:
NCMI Traditional
%
%
Male 87.3
70.5
Female 12.7
29.5
Sociodemographics
Characteristics by Group
• African American: 81%
• White: 7.3%
• Hispanic: 9.4%
Behavioral Characteristics
• Social Support Mean:
49.1
• Depressive Symptoms:
17.8
• Psychological Well Being:
65.0
Behavioral
Characteristics by Group
NCMI
(n = 283)
%
Lifetime
13.8
IDU***
Current
IDU***
7.2
Current non
injection
66.4
drugs
Traditional
(n = 237)
%
27.4
16.5
58.7
Behavioral Characteristics
• Daily alcohol use:
16%
• Daily drug use:
22%
• Years smoked:
15
Behavioral Characteristics
• Intent to adhere:
83.6%
• Wanted to take INH
81.1%
• Medical Discharge:
14.2%
Compliance Status by Group
NCM
(n = 283)
Completed
Treatment***
Yes
Intention to
Treat ***
Traditional
(n = 237)
%
%
72%
46%
60%
40%
Associations by Treatment
Completion
Completers Non-Completers
(n = 254)
(n = 266)
M
M
Age**
42.5
40.5
Associations by Treatment
Completion
Completers
(n = 266)
Ethnicity**
Black
White
Hispanic
Recruit***
ER Shelter
Drug Recov
Non-Completers
(n = 254)
%
86.8
5.6
6.4
%
74.8
9.1
12.6
83.8
16.7
74.8
25.2
Key Characteristics & Treatment
Completion
Social Support:
Mean: 49
Depr. Sym
Mean: 18
Psych. Well
Being
Mean: 65
Associations of Key Characteristics
& Treatment Completion
Completers Non-Completers
(n = 254)
(n = 266)
Lifetime IDU
N
44
%
16.5
N
60
%
23.6*
IDU
25
9.4
34
13.6
Non-injection
drugs
167
62.8
160
63.0
Associations of Key Characteristics
& Treatment Completion
Completers Non-Completers
(n = 254)
(n = 266)
Daily Alcohol
Use
Daily Serious
Drugs
N
34
%
12.8
N
49
%
19.3*
44
16.6
66
26.3**
Logistic Regression Results for
Completion of LTBI Treatment
Adjusted
Odds Ratio
95%
CI
NCMI Group
2.25
1.55-3.28
Age
1.03
1.002-1.05 .034
Black
1.70
1.02-2.84
.042
Sex
1.08
0.67-1.75
.758
P Value
.001
Logistic Regression Results for
Completion of LTBI Treatment
Adjusted
Odds Ratio
95 %
CI
P Value
0.52
0.27-1.01
.055
Daily Alcohol Use 0.59
0.36-0.98
.043
Hospitalized
Past 6 Months
Efficacy of Intervention Using
Adjusted Odds Ratios and 95% CIs
•
•
•
•
•
•
•
•
Males
Females
Black
Veteran
Daily ETOH
Fair/Poor Health
Homeless Shelter
Distressed
•
•
•
•
•
•
•
•
2.51 (1.60, 3.93)
5.80 (1.72, 19.57)
2.60 (1.69, 4.02)
4.34 (0.87, 21.73)
10.41 (2.48, 43.68)
3.27 (1.30, 8.25)
5.10 (1.79, 14.52)
2.76 (2.00, 6.37)
Summary
Findings to date indicate that
72% of homeless persons in the
NCM program have completed
treatment for LTBI while 46% of the
Traditional group have completed
treatment for LTBI.
Conclusions - 1
Completers were more likely to be older,
African American and recruited from a
homeless shelter. Non completers were
more likely to be Hispanic, and have used
lifetime injection drugs, drink alcohol daily,
or use serious drugs daily.
Conclusions - 2
Strategies utilized by nurses
and outreach workers in the NCM
program including case management,
incentives for enhancing compliance
and relocating clients to return for DOT
are helpful. Compliance to a medication
regimen among homeless populations
at risk for HIV is possible with effective
strategies.
Publications
• Nyamathi A., Christiani, A., Nahid, P., Strehlow, A., Gregerson, P.,
Morisky, D., & Leake, B. (2006). A Randomized Controlled Trial of
Two Treatment Programs for Homeless Adults with Latent
Tuberculosis Infection. IJTLD, 10, 775-82.
• Schumann, A., Nyamathi, A., Stein, J. (2007). HIV Risk Reduction in
Nurse Case – managed TB and HIV Intervention among Homeless
Adults. J Hlth Psy, 12, 833-843.
• Nyamathi, A., Stein, J. A., Schumann, A., Tyler, D. (2007). Latent
Variable Assessment of Outcomes in a Nurse Case Managed
Intervention to Increase Latent Tuberculosis Treatment Completion
in Homeless Adults. Health Psychology, 26, 68-76.
• Nyamathi, A., Nahid, P., Berg, J., Christiani, A., Aqtash, S., Morisky,
D., & Leake, B. (in press). Efficacy of a Nurse Case Managed
Program Among Subgroups of Homeless Adults. Nursing Research