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Hepatitis C (HCV) and HIV co-infection has emerged as a major health problem in Puerto Rico, particularly among injecting drug users (IDUs). We developed and implemented a multimedia educational intervention for HIV-infected IDUs, based on the Health Belief Model and Social Cognitive Theory.
To evaluate its acceptability a group of 42 participants completed a written questionnaire immediately following each intervention component.
Participants were 85% male, the mean age was 41.6 ± 9.2 years and mean educational level was 9th grade. More than 73% respondents reported that the computer-based program was very easy to operate. More than 83% agreed that the audio and video tools highly facilitated their learning process, and 71% agreed that the session durations were adequate. Additionally, they reported a high incremental increase in perceived knowledge regarding: HIV/HCV co-infection, HCV infection risk behaviors, HCV complications, HCV preventive measures, and HCV diagnosis and therapy. Most of the participants favored the dissemination of this intervention.
The study found a very good acceptability and feasibility of the computerize intervention in the study group. This new technology that includes audio visual tools in its design kept the participants’ attention and interest, while increasing HIV/HCV co-infection knowledge. Subsequent studies will evaluate the efficacy of this intervention, investigating changes in knowledge and risk behaviors among HIV-infected individuals.
HIV infection has dramatically changed the morbidity and mortality profile throughout the word in the last two decades. After the introduction of highly active antiretroviral therapy, AIDS-related opportunistic conditions decreased while chronic conditions such as Hepatitis C virus (HCV) infection have become a major contributor to the disease prognosis among HIV infected subjects.1–7 More than 200,000 HIV infected persons are co-infected with HCV in the United States.2–4 HIV-HCV are blood pathogens and the practices and behaviors associated with intravenous drug (IVD) use are their most common risk factors.8–11 Most co-infected individuals are injection drug users (IDUs), .1–3,8,9, Co-infected patients have been reported to have a rapid progression to cirrhosis and end stage liver disease.5–9
Puerto Rico ranked fifth in the incidence rate of AIDS (26.4 per 100.000) among all US states and territory. 12 Injection drug use is the most common modes of HIV transmission in Puerto Rico. HCV co-infection rates in IDUs may exceed 80% in Puerto Rico.9 No previous prevention strategies directed to reduce the HCV infection, re-infection or super-infection in Hispanic HIV IDUs had been reported in the literature.
In the absence of a vaccine or an effective prophylactic therapy for HCV infection, preventive strategies that limit the spread of these viruses needs to be considered.12,13 The advances in new technology permits the use of multimedia to disseminate information that addresses patient’s education. 14–16 Consequently, we developed a multimedia educational intervention for Hispanic IDUs with HIV. The current study evaluated the acceptability of this educational intervention among a group of HIV infected individuals.
Individuals targeted for this intervention were HIV-infected IDUs attending the Retrovirus Research Center clinic in Bayamón Puerto Rico for HIV-related care from February through August the 2006. Participants were escorted by a health educator to a private office where they completed two self-administered questionnaires collecting demographic, clinical and behavioral data. After the enrollment and before each computerized intervention session, each participant received a 10 minute orientation on how to use the computer and navigate the program. Subsequently, they received the computer-based interventions under the supervision and assistance of the health educator. The first session was offered at study entry and the others, two, four and eight weeks later. Additionally, participants were tested for HCV at study entry.
The intervention was developed using Power-Point software (Microsoft Corp., Redmond, Wash). All four sessions included text, cartoons, pictures and an audio tutorial. Each session was designed to be completed within 25 to 35 minutes.
The theoretical frameworks guiding the intervention design were the Health Belief Model (HBM) and Social Cognitive Theory (SCT).17–19 The Health Belief Model describes the relations between essential factors involved in behavioral change. Of particular importance to our intervention were the personal motivations for behavior change, including perceptions of the risks and benefits of disease and behavior change. Our intervention sessions focused on increasing HCV knowledge, HCV susceptibility perception and HCV protective measure efficacy.
Social cognitive theory addresses four components of learning: attention, retention, reproduction and motivation. The multimedia used in our intervention attracts individual attention; thereby improving retention and the ability to reproduce or copy a modeled behavior.18–19 Moreover, we anticipated that the four installments of the intervention would provide reinforcement of the messages, further enhancing retention, reproduction and motivation for behavior change.
The first session was designed to increase the HCV knowledge about HCV as a health problem and its adverse effects in the prognosis of HIV infected patients. Its objective was to educate individuals about hepatitis, especially HCV, its liver damage and its negative effects on the HIV condition and its management. The topics covered in this session were 1) the role of the liver; 2) how hepatitis affects the liver; 3) HCV infection; and 4) HCV-HIV co-infection. The second session was designed to increase the perception of susceptibility to HCV infection. The topics covered in this session were 1) modes and routes of HCV transmission; and 2) behaviors and practices that increase risk. The third session taught participants about HCV risk behaviors and prevention strategies. The session included the benefits of the prevention methods and common barriers to their implementation. The final session reinforced the importance of HCV prevention. It aimed to motivate the initiation or maintenance of these practices and reduce the barriers to their practice.
All four sessions were reviewed and evaluated before the study implementation by an expert panel composed of two primary physicians, one gastroenterologist and one education professor. The reviewers agreed that the intervention should be created in a simple way appropriate for people with little education. They concurred that the content and form of the intervention were adequate and covered the primary goals of the study.
At the end of each of the four sessions, each participant completed a self-administered form asking about difficulties encountered in using the computer, comprehension of the audio-visual aids, question clarity, and session duration and content. They were also asked about their perception of knowledge gain regarding HCV/HIV co-infection, disease severity, diagnosis, risk behaviors and treatment and prevention. The computer use responses ranged in a scale from 1 (difficult) to 3 (very easy). Agreement type responses ranged from 1 (highly disagree) to 4 (highly agree). Knowledge improvement measures ranged from 1 (none) to 4 (a lot).
The Statistical Package of Social Sciences (SPSS Inc., Chicago IL) program was used to conduct univariate and bivariate analyses. Univariate analysis was used to evaluate the percentage distribution of the feasibility and knowledge component in each of the four session or subgroups. Bivariate analyses with Chi-square and Fisher exact tests, using a two-tailed alpha level of .05, were used to evaluate and compare feasibility and knowledge differences between sessions. Differences were evaluated in the overall group and by subgroups, stratified by gender, age, educational level and active injection drug use.
During the seven month study period 65 patients eligible for the study attended the clinic, 48 were asked to participate and 42 completed the enrollment survey. Of the 42 HIV infected participants, 36 (85.7%) were male, all had a history of IVD use and 36 (85.7%) were co-infected with HCV. The mean age was 41.6 years with a standard deviation of ± 9.2 years. The mean educational level was 9th grade. Half of the participants (52.0%) reported injecting drugs in the last six months. All 42 participants completed the first intervention session; 39 completed the second; 38 completed the third; and 37 completed the fourth session.
None of the 42 participants reported computer experience before the intervention. Only one in five (21.4%) reported that it was very easy to use after the first session. But three quarters (73.0%) reported ease of use after the fourth session (Table 1). This difference was statistically significant and showed a significant linear trend. The difference remained significant when accounting for educational level and recent injection drug use (Tables 2 and and33).
Most participants (61.9%) initially agree highly that this multimedia intervention facilitated their learning process and this proportion increased significantly over the four sessions (Table 1). This differences and the linear trend remained significant after stratifying by educational level and recent injection drug use (Tables 2 and and3).3). A similar trend was observed, when evaluating whether the audio aids used in the each session facilitated the learning process; 59.5% highly agreed after the first session and 89.2% after the fourth session. This difference and the linear trend remained significant when stratifying by educational level and recent injection drug use. Likewise, when evaluating whether the visual aids facilitated the learning process, the percentage of high agreement increased significantly after each of the four sessions. The percentage difference and the linear trend remained significant after stratifying by educational level and recent injection drug use.
Most participants agreed highly that the duration of the each session was adequate and agreed to recommend the intervention to others. Some recommended that the two last sessions be even longer.
Approximately 81% to 95% of the participants reported that the intervention improved their knowledge of liver function, hepatitis and hepatitis C infection (diagnosis, complications and treatment (Table 4). Similarly they reported a significant improvement in their knowledge related to the HCV risk behaviors after the intervention process, particularly in the injecting drug use practices (94.0%). Participants also reported an increment in their knowledge regarding HIV-HCV co-infection, and its detrimental effects.
The areas of highest knowledge improvement were those related to injecting drugs (94.9%), inhaling drugs (89.7%) and sex (89.7); and to their corresponding prevention risk reduction strategies (Table 4).
We have found this newly developed HCV computerized intervention to be a viable approach to health related behavior changes in a high risk Hispanic population. To our knowledge there have been no previous HCV educational multimedia interventions culturally adapted to the Hispanic population. As reported by others,14–16 this type of intervention has the potential advantage of improved health status in several major areas of care. Computer-based strategies offer an opportunity for systematically exposing high risk individuals to individually relevant, effective health promotion messages.14–16 The present intervention may reduce HCV primary infection as well as re-infection and super-infection with the virus. In addition improvement in HCV knowledge in already infected persons could reduce the spread of the virus to uninfected IDUs. Because knowledge improvement was measured through participants’ perceptions, their reports could be affected by a desire to give socially desirable answers. Additionally, the small sample size could have a possible limitation effect in the study findings. A pre and post intervention study is currently underway to objectively assess changes in HCV knowledge after the computer-based intervention.
These multimedia tools hold promise for filling a critical gap in HIV and HCV infection prevention. In Puerto Rico the majority of persons at risk for these conditions are Spanish speakers, medically indigent, and with a low educational level – all barriers limiting their access to opportune and adequate primary, secondary and tertiary prevention. To address illiteracy, our intervention uses cartoons and pictures that illustrate in detail, the most common risky behaviors and rituals performed by local person when preparing, using and sharing their drugs. To enhance understandability and acceptability, the intervention employs the most common jargon used by IDUs. The program is narrated by a Puerto Rican man in a local accent, which should decrease cultural communication barriers. These approaches could explain the high acceptance of the intervention despite participants’ lack of formal education and prior computer experience.
IDUs characteristically have little patience, low concentration levels and low self esteem; characteristics that obstruct their learning process by the classic reading methods. Consequently cartoons, pictures and narration are important tools in the design and creation of effective educational intervention directed to this population. Computerized interventions more easily capture and maintain the participants’ attention to the sessions. Higher attention and higher interest leads to knowledge improvement as reported by the study participants. These findings endorse the potential benefits of multimedia programs for the dissemination of HCV prevention strategies in populations with a high risk level. Moreover, the improvement of the participants’ computer experience acquired through the sessions, could produce an elevation of the individual self esteem, which could, in turn, directly or indirectly enhance their learning capacity.
This multimedia intervention provides additional benefits to both health care providers and their patients. This electronic intervention could be disseminated inexpensively through the internet to a wide number of health care providers or health educators and then used in clinics or other settings. For the patients, the intervention is private (requiring only interaction with a computer) and allows them to move at their own pace.
If this intervention decrease HCV infection among drug users, it will lower the incidence in a hard-to-reach population and thereby decrease an important and intransigent health disparity.
The present study was sponsored by the RCMI/ NIH Grant number IU54RR0195071 and G12RR03035. We would also like to thank Mayra Soto, the program case manager, and Christine Miranda, the program health educator, for their help and collaboration.
Angel M. Mayor, Retrovirus Research Center, Internal Medicine Department, Universidad Central del Caribe, School of Medicine.
Diana M. Fernández, Retrovirus Research Center, Internal Medicine Department, Universidad Central del Caribe, School of Medicine.
Héctor M. Colón, Center for Addiction study, Universidad Central del Caribe, School of Medicine.
James C. Thomas, Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill, NC.
Robert F. Hunter-Mellado, Retrovirus Research Center, Internal Medicine Department, Universidad Central del Caribe, School of Medicine.