The interactive seminar: An educational approach for voluntary HIV testing in a drug dependence treatment unit

The Interactive Seminar: An Educational Approach Voluntary HIV Testing in a Drug Dependence Treatment Unit LAILA SEDHOM, WILLIAM LILIETH

PHD,

RN,*

STEPANYK, CLARKE,

MA,

RITA REIS WEICZOREK, BS,

RNC,$

RN,”

SHEILA

EDD,

BRITTON,

AND GLADYS TORRES,

Acquired immune deficiency syndrome (AIDS) is a pandemic disease with no known cure and limited effective strategies for prevention and control. it is one of the most devastating illnesses in contemporary society, and since 1662, certain populations, including intravenous drug users (IVDU), have bsen targeted as being at high risk for AIDS. Education is one strategy that seeks to address AIDS and the n&s of IVDU. This retrospective study focused on the use of the interactive seminar or small-group discussion as an educational method to identify and describe its effect on the mte of voluntary human immunodeficiency virus (HIV) testing among male subjects in a drug dependence treatment unit (DDTU). The subjects, 25 to 62 years old, were in treatment at a Medical Center for Veterans that was located in an urban environment. The medical records of 116 patients admitted to the unit during the year before and the year after the introduction of an HIV interactive seminar were studied. Analysis of data showed that drug users who participated in the interactive seminar had a higher rate of voluntary HIV testing than did those who did not participate; IVDU who participated in the interactive seminar had a higher rate of voluntary HIV testing than IVDU who did not participate in the seminar; drug users who completed the detoxification treatment and participated in the intemctive seminar had a higher rate of voluntary HIV testing than did those who did not participate in the interactive seminar. Results demonstrated that drug users volunteered for HIV *Associate Professor, College of Nursing, State University of New York, Health Science Center at Brooklyn, NY. tDean and Professor, College of Nursing, State University of New York, Health Science Center at Brooklyn, NY. $%aff Nurse, Brooklyn Veterans Administration Medical Center, NY. §Quality Assurrance Coordinator, Brooklyn Veterans Administmtion Medical Center, NY. “Nursing Instructor, Brooklyn Veterans Administration Medical Center, NY. !/Nursing Research Specialist, Brooklyn Veterans Administration Medical Center, NY. Address correspondence and reprint requests to Dr Sedhom: College of Nursing, SUNY-Health Science Center at Brooklyn, 450 Clarkson Ave, Box 22, Brooklyn, NY 11203-2098. Copyright 0 1994 by W.B. Saunders Company 8755-7223/94/1005-0010$03.0010

RN,

For

FAAN,“f

MA, RN,$ EDD,

RN7

testing and did benefit from interacting with other drug users and with a nonjudgmental professional who spoke their language. (index words: Drug users; Interactive seminar; Intravenous drug use; Voluntary HIV testing) J Prof Nurs 70:313-316, 1964. Copyright 0 1994 by W.B. Saunders Company

A

CQUIRED IMMUNE DEFICIENCY syndrome (AIDS) was identified as a reportable disease by the Centers for Disease Control (CDC) in 198 1. The World Health Organization (WHO) has indicated that, by the year 2000,40 million people in the world are expected to be infected with the human immunodeficiency virus (HIV) (Altman, 1991). In the 1990 survey, there were 43,000 cases of AIDS reported in the United States: 38,000 men and 5,000 women (Navarro, 1991). In 1992, the CDC revised the definition of AIDS, and it is anticipated that the change could subsequently increase the number of individuals confirmed as having the disease. Currently, the definition of the person with AIDS includes any HIVinfected person with a count of 200 or fewer CD4 cells (T cells) per cubic millimeter of blood. In healthy individuals, this immune system cell numbers approximately 1,000 cells per cubic millimeter of blood. Intravenous drug users (IVDU) account for a substantial number of the AIDS cases in the United States. The number of new cases of AIDS among IVDU has been increasing steadily. In 1992, there were 40,000 cases of AIDS among IVDU reported as compared with 1988, when 12,000 cases were documented (Caussy, Weiss, Blattner, French, Cantor, Ginzburg, Altman, and Geodert, 1990). Intravenous drug use continues to be the second most common risk behavior associated with AIDS in developing countries (Stimson, 1990). New York City has the largest number of reported AIDS cases in the country (Navarro, 1991), with intravenous (IV) drug use constituting 40 per cent of

Journal of Professional Ntlrsing, Vol 10, No 5 (September-October),

1994:

pp

3 13-3 18

313

SEDHOM

314

the diagnosed

cases (New York City Department

Health,

1990).

creasing

in the urban

continuing

The prevalence

IV drug

of

of HIV has been in-

environment

partly

use and increasing

because of heterosexual

transmission. Human

(interactive

able. In the absence tive treatment,

virus is currently

incur-

of an effective vaccine and cura-

prevention

of HIV

transmission

become the major focus for controlling

has

the pandemic

illness.

(Phipps,

free frequently

share their experiences

dicted substances

Group discussion

their

perceptions of HIV,

body testing. discussion control

group

of a 90-minute

discussion)

interactive

conducted

selor on the rate of voluntary

HIV

testing

among unit

(DDTU).

The research focused on one available method

dependence

treatment

in

cational

a drug

to reach and engage

most at risk for HIV infection can be used by health ventive

educational

Data

to develop

specifically

meet the needs of this particular

edu-

those who are

and transmission.

care providers

programs

(small

by an HIV nurse coun-

patients

high-risk

and

ad-

who have the

beliefs

about

AIDS,

of HIV anti-

No studies have focused on small group

as an educational

strategy populations

to prevent

or

of IVDU.

Hypotheses

the ef-

seminar

and

allows drug users to

and the meaning

AIDS in high-risk

1. Drug fectiveness

in a sup-

with using

with other individuals

Three hypotheses was to evaluate

problems

1986; Weddington

Drug users whose goal is to live drug and alcohol

transmission

of this study

im-

own behavior,

1989).

explore

The purpose

knowledge

in question,

for their

to share similar

atmosphere

same problem.

lndiviciuals involved in a small group are provided opportunities to share similar problems in a supportive and responsive atmosphere . . ,

patients’

the subject

responsibility

and allows them Brown,

recognizes

regarding

plies persons’ portive

immunodeficiency

seminar)

and opinions

ET AL

pre-

designed

to

group

of

patients.

were tested in this study:

users who participate

interactive

seminar

in a 90-minute

will have a higher

rate of

voluntary HIV testing than those who do not participate in the seminar. 2. Intravenous

drug users who participate

90-minute interactive seminar higher rate of voluntary HIV IVDU who do not participate

in a

will have a testing than

in the seminar.

3. Drug users who complete a detoxification treatment and participate in a 90-minute interactive voluntary

seminar

will have a higher

HIV testing

rate of

than those who com-

plete a detoxification treatment and do not participate in the interactive seminar.

Literature Review Method The literature

review indicates

that education

grams directed toward AIDS prevention users are concerned with disseminating rather than with strategies Jarlais & Friedman, Friedman, Hopkins, 1986;

and

Schuster,

for changing 1988; Kleinman,

& DesJarlais, 1988).

pro-

among drug information behavior (Des Goldsmith,

1990; Ginzburg,

Educational

strategies

DESIGN

One hundred

eighteen

randomly

selected

medical

records of patients admirted to a Veterans Affairs Medical Center (VAMC) DDTU during the year (May 1, 1988 through

April 30, 1989) before and the year

(May 1, 1989 through

April

30, 1990) after the in-

effective in influencing attitudes and changing behavior (Flaskerud, 1992). Educational approaches that involve groups provide interactional experiences that

troduction of the 90-minute HIV interactive seminar were studied. The retrospective study first received the approval of the Institutional Review Board. The researchers supervised the data collection by registered professional nurses at a VAMC in an urban setting.

alter behavior, attitudes, and ideas. Individuals involved in a small group are provided opportunities to share similar problems in a supportive and responsive atmosphere and to learn new behaviors (Phipps, 1986; Sampson & Marthas, 1989). Small group discussion

The researchers instructed the data collectors in methods to be used before the start of the study. To facilitate data collection, the researchers developed a 25-item chart audit form. Based on review of the literature and the biopsychosocial history assess-

that offer participants an opportunity feelings openly in a nonthreatening

to express their atmosphere are

315

INTERACTIVE SEMINAR: VOLUNTARY HIV TESTING

at the DDTU,

of daily living

on demograph-

were required

ment tool used by health professionals the audit

form included

ics, sexual practices, involving HIV testing

numbers

could be confirmed

report with medical

The content seminar

validity

curriculum

and treatment. The content

for the audit

the definition system,

Subjects for this study were men living in the urban

and

environment

in the field of AIDS diagnosis

detailed

interactive

of transmission,

instructions

8 to 10 patients.

of the

to the group’s questions

were blacks,

prevention

32 (27.4

about needle cleaning

constituted

of seeking and available treat-

46.1

and encouraging

of subjects’

Protes-

per cent) were white,

per cent,

Intravenous

and 21

drug users

and non-IVDU,

53.9 per

cent, of the study population.

The age at which sub-

jects admitted

use ranged

to first drug

between

8

years and 43 years, with a mean of 17.7 years.

group mem-

Results

attendance records

Subjects in the study indicated

at the

drug,

maintained

with cocaine,

major substances who attended testing.

SElTlNG

ference

The unit selected for the study was a locked DDTU for admission.

abused

using more than one

crack, and heroin 23 volunteered

for HIV testing

for HIV

the seminar,

(Fig 2). This dif-

significant

(P

=

1 was supported.

hypothesis

DRUGS

PERCENT

SUM 0.8

MORPHINE c LSD

2.5

SPEED

4.2

VALIUM

5.9

TOBACCO

13.6

POT

28.8

HEROIN

41.5

CRACK

43.2

ETOH

71.2

COCAINE

78.8 20

30

40 PERCENT

Figure

1.

50

6b

SUM

Drugs abused by subjects.

7b

as the

(Fig 1). Of the 62 subjects

the seminar,

was statistically

Therefore,

Activities

alcohol,

Of the 33 who did not attend

three volunteered volunteered

and

64 (54.7 per cent)

was placed on responding

seminar was established through by the HIV nurse educator.

where patients

Catholic

studied,

(17.9 per cent) were Hispanic.

bers to verbalize their concerns and feelings about HIV. The interactive seminar was led by a male nurse Verification

was predominantly

Of the 118 subjects

tant.

The size of the group ranged from Emphasis

of New York City. Ages ranged from 25

to 62 years, with a mean age of 37.2 years. Religious

seminar

of AIDS, basic functions

methods

and testing.

counselor.

at rehabilitation. SAMPLE

by a panel of four

and safe sex practices), the benefits completing detoxification treatment, ment,

tempts

form and the

nurse specialists

of the 90-minute

immune (including

so

the lab-

preference

included

of rules or

from the program.

record information.

of two clinical

experts

Patients

The average length of stay in the program was 28 days. Records indicated that most subjects had previously made multiple at-

Patients’

by matching

were estimated

experts consisting two physician

of needles.

were used for identification

to follow the unit’s contract

be dismissed

use, and risk behaviors

the use and sharing

social security oratory

information

substance

on the unit were structured.

6b

.0035).

316

SEDHOM ET AL

90 MIN. SEMINAR

/

/

/

YES

NO

YES

Figure 2.

Voluntary HIV testing among those who attended and those who did not attend the 90-minute seminar (Fisher’s Exact Test P = .00357; n = 95).

Of the 53 subjects attended

who admitted

the 90-minute

seminar,

Of the 17 who attended

14 volunteered

for HIV testing.

HIV testing significant

10 volunteered

(Fig 3). This difference (P = .00029),

ported. Of the 53 subjects tion treatment, not attend.

who completed

19 attended

for

was statistically

and hypothesis

Of the 19 subjects

and 36

the seminar,

Of the 36 subjects

the seminar,

Figure 4.

Voluntary HIV testing among those who completed the treatment and attended the 90-minute seminar and those who completed the treatment and did not attend the seminar (Fisher’s Exact Test P = .03580; n = 53).

IV drug use, 17

interactive

did not attend.

who did not attend

2 was sup-

the detoxifica-

the seminar

and 34 did

who attended

the sem-

inar,

16 volunteered

Of the 34 sub-

the seminar,

18 volunteered

for HIV testing

(Fig 4). This difference

cally significant

(P =

.0358),

was statisti-

and hypothesis

3 was

supported. Additional analysis showed that there was a statistically significant difference in relation to voluntary HIV testing treatment seminar

between and

those who did not complete

attended

the

90-minute

and those who did not complete

the

interactive the treat-

SEMINAR

SEMINAR

/

/ YES 17

/

Voluntary HIV testing among IV drug users who attended the 90-minute seminar and IV drug users who did not attend the seminar (Fisher’s Exact Test P =

Figfire 3.

n =

YES

NO 36

VOL. HIV TESTING

.00029;

for HIV testing.

jects who did not attend

ATTENDED AlTENDED

NO

VOL. HIV TESTING

VOL. HIV TESTING

53).

NO

VOL. HIV TESTING

Figure 5.

Voluntary HIV testing among those who did not complete the treatment and attended the go-minute seminar and those who did not complete the treatment and did not attend the seminar (Fisher’s Exact Test P = .03237; n = 65).

317

INTERACTIVE SEMINAR: VOLUNTARY HIV TESTING

ment and did not attend 5). Of the

65 subjects

detoxification

treatment,

the seminar who did

not complete

and

the seminar,

Of the 56 subjects

the treatment

21 volunteered

seminar,

the

the seminar

who did not complete

and attended

teered for HIV testing.

not complete

9 attended

56 did not. Of the 9 subjects the treatment

(P = .03) (Fig

their language. end to high-risk was evident

7 volun-

patients,

who did

physicians,

and did not attend

the

Participation

nar and the willingness

tant

behavior.

completed

and psychologist),

information.

infection.

who attended the interactive seminar volunteered for HIV testing . . .

procedure

function

was conducted

analysis

with

to determine

were effective in discriminating

between

were more likely

for HIV

to volunteer

sponse . Only

the chi square is statistically tion between

these variables

ing is a moderate

cent) indicated other question

in 115 (97.5

testing

and

charts indicated

that the patients

and these variables

ac-

(Table

1).

sexual intercourse.

tient sexual orientation patients’

charts

sponsible taking,

and the interactive

seminar

about

given

about

for patient’s

sexual

history.

Failure

the subjects

by a HIV

nurse

from this study,

continuing

ucation,

reduce nurses’ anxieties

topics about sexuality,

and with

which is a step toward prevention.

a nonjudgmental

users benefitted

The

1.

and history to record

education

pro-

may provide

and discomfort

and improve

edwith

documentation.

from

with other drug users professional

who spoke l

TABLE

on

are re-

grams that bring nurses together to discuss sexual history taking and sexual counseling, followed by

HIV testing,

that drug

Nurses

assessment

in the form of role playing,

demonstrated

Moreover,

any information

(eg, sharing).

practice

study

response to pa-

was “no problem.”

physical

Two

did not use condoms

A common

counselor. The study indicated that most of subjects who attended the interactive seminar volunteered for

being in a group and interacting

the

the use of condoms

per cent) charts.

did not include

behavior

including

findings information

that

complete sexual history data can interfere with effective patient education and nursing care. In view of the

Discussion yielded

No information

needle-using

indicated

that the subject had one partner. Anasked by the researchers was related to

condoms.

HIV test-

on the

Of the 118 charts

and one chart (0.8 per

was documented

and voluntary

form devel-

a question

per cent)

partners,

that

count only for 20 per cent of the variance

This study

included

who

the correla-

risk for HIV

the chart audit

11 (9.3

had multiple

during

sexual behavior

to their

subjects

significant,

correlation,

significant

variables

those who were less likely to volunteer for HIV testing (8, n = 118,~’ = 21.015, P < .05>. Although

impordid not

106 (89.9 per cent) did not have any re-

reviewed,

a stepwise

it

forms of

professionals

of subjects’ sexual partners.

subject A discriminant

history

about the patients’

For example,

number

data collection,

were missing

Some health

oped by the researchers

mosfsubjects

semi-

by the staff on the unit (nurses,

that was especially

. . .

During

that the biopsychosocial

record information

for HIV testing.

in the interactive

to be tested may not mean an

Summary of Discriminant Function Analysis for Predicting Voluntary/Nonvoluntary HIV Testing

step

Variables Entered

Wilks’ Lambda

P

1 2 3 4 5 6 7 8

HIV seminar Hispanic White Religion Divorced Past treatment Married Opposite sex

,917 ,886 ,871 ,849 ,839 ,826 ,816 ,799

.0038 .0029 .0040 .0035 .0050 .0061 .0078 .0072

.

other high-risk groups such as women and adolescents deserve attention. l

Further

Function Eigenvalue = 0 25 Canonical Correlation = 0.44. After function: Wilks’s Lambda, 0.799; x2, 21.015; df, 8; P, ,007.

discussion

research on the effectiveness

of small group

on voluntary

of other

HIV

testing

high-

risk groups such as women and adolescents deserve attention. The current sample is limited by its homogeneity, and the results may not be wholly representative. An experimental or quasi-experimental study might be conducted in which subjects would be exposed to a series of carefully planned small group discussions. The effect of these small group discus-

318

SEDHOM ET AL

sions on the rate of voluntary

HIV testing

then could

be assessed.

specifically

The primary resulting dinal

strategy

in behavioral

study

cussion

Nursing

for prevention changes.

programs

changes

and in-service

used for IVDU

The researchers been influenced

education

by the timing

should

as one of the teaching

dated

and

increases

health care providers

changes

promoted

the characteristics ucational

After

were man-

education

of

transmitted

diseases,

onstrated identify

behavioral

signed

drug Ideally,

they should

be involved

in designing

anxieties

gender,

race, edof sexually

history,

or other

be used as a basis to of the IVDU population

seminars,

be de-

of IVDU?

should teach students

in a thorough

how to take

and nonjudgmental and other teaching

manstrat-

to explore their feelings about

use before interacting

students’

Can

for testing

? Can interventions

to reach sex partners

egies that help students

drug users listen to and learn from each

for testing.

of a group that has dem-

changes

interventions

character-

knowledge

childbearing

and target subgroups

for specific

ner. Role playing,

implications for Nurse Educators and Researchers

other.

employment,

Nurse educators

and consumers.

programs

who volunteer

in terms of HIV status, level,

drug history

Intravenous

of IVDU

factors? Can characterization

of this study.

educational

to meet the needs of IVDU.

More research is needed to find common

be defined

are aware that the data may have

legal and pharmacological

preventive

designed

istics among IVDU who do volunteer

dis-

at risk for AIDS.

1989,

fiscal

a longitu-

of small group

is recommended.

small group discussion

strategies

is education

Therefore,

to assess the impact

on behavioral

include

and implementing

with

clients

may reduce

and discomfort

with

topics about

drug use and therefore

may improve

documentation.

References Altman, L. (1991a, June 18). Who says 40 million will be infected with AIDS virus {Medical science). The New York Times, p. 3.

Altman, L. (199 lb, June 20). Cost of AIDS care in U.S. is seen at $5.8 billion in 91. The New York Times, p. 4. Caussy, D., Weiss, S., Blattner, W., French, J., Cantor, K., Gintburg, H., Altman, R., & Goedert, J. (1990). Exposure factors for HIV-l infection among heterosexual drug abusers in New Jersey treatment programs. AZDS Research and Human RetroYiruses, 6( 12), 1459- 1467. Des Jarlais, D., 8r Friedman, S. (1988). HIV infection among persons who inject illicit drugs: Problems and prospects. Journal of Acquired Immune Deficiency Syndromes, l(3), 267-273. Flaskerud, J. (1992). Psychosocial aspects. In J. Flaskerud and P. Ungvarski (Eds.), HIVIAIDS: A guide to nursing care (pp. 239-274). Philadelphia: W.B. Saunders. Friedman, S., Des Jarlais, D., Sotheran, J., Garber, J., Cohen, H., & Smith, D. (1987). AIDS and selforganization among intravenous drug users. fntewtational journal of AaUctions, 22(3), 201-219. Ginzburg, H. (1986). Health education and knowledge assessment of HIV-III diseases among intravenous drug users, Health Education Quarter/y, 13, 373-382. Kleinman, P., Goldsmith, D., Friedman, S., Hopkins,

W., & Des Jarlais, D. (1990). Knowledge about and behaviors affecting the spread of AIDS: A street survey of intravenous drug users and their associates in New York City. InternationalJournu1 of the Addictions, 25(4), 345-361.

Navarro, M. (1991, August 8). U.S. widens rules on who had AIDS. The New York Times, p. 2 1. New York City Department of Health (1990, October 3 1). AIDS surveillance update, New York: New York City Department of Health, AIDS Surveillance Unit. Phipps, L. (1986). Group work: History and overview. In E. Janosik & L. Phipps, Life cycle-groupwork in nursing (pp. 3-15). Boston: Jones and Bartlett. Sampson, E., & Marthas, M. (1989). Group proceJIfor the health profxrions. New York: John Wiley and Sons. Schuster, C. (1988). Intravenous drug use and AIDS education. Public Health reports, 103(3), 261-266. Stimson, G. (1990, June). The prevention of HIV infection in injecting drug users: Recent advances and remaining obstacles. Paper presented at the Sixth International Conference on AIDS, San Francisco. Weddington, W., & Brown, B. (1989). Counseling regarding human immunodeficiency virus antibody testing: An interactional method of knowledge and risk assessment. Journal of Substance Abuse Treatment, 6(2), 77-82.