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1.  Prevalence and correlates of HIV among men who have sex with men in Tijuana, Mexico 
Men who have sex with men (MSM) in developing countries such as Mexico have received relatively little research attention. In Tijuana, Mexico, a border city experiencing a dynamic HIV epidemic, data on MSM are over a decade old. Our aims were to estimate the prevalence and examine correlates of HIV infection among MSM in this city.
We conducted a cross-sectional study of 191 MSM recruited through respondent-driven sampling (RDS) in 2012. Biological males over the age of 18 who resided in Tijuana and reported sex with a male in the past year were included. Participants underwent interviewer-administered surveys and rapid tests for HIV and syphilis with confirmation.
A total of 33 MSM tested positive for HIV, yielding an RDS-adjusted estimated 20% prevalence. Of those who tested positive, 89% were previously unaware of their HIV status. An estimated 36% (95% CI: 26.4–46.5) had been tested for HIV in the past year, and 30% (95% CI: 19.0–40.0) were estimated to have ever used methamphetamine. Independent correlates of being infected with HIV were methamphetamine use (odds ratio [OR]=2.24, p=0.045, 95% CI: 1.02, 4.92) and active syphilis infection (OR=4.33, p=0.01, 95% CI: 1.42, 13.19).
Our data indicate that MSM are a key sub-population in Tijuana at higher risk for HIV. Tijuana would also appear to have the highest proportion among upper-middle-income countries of HIV-positive MSM who are unknowingly infected. More HIV prevention research on MSM is urgently needed in Tijuana.
PMCID: PMC4323407  PMID: 25669423
men who have sex with men; correlates of HIV infection; HIV prevalence; US–Mexico border; global public health; respondent-driven sampling
2.  Initial validation of a computerized version of the UCSD Performance-Based Skills Assessment (C-UPSA) for assessing functioning in schizophrenia 
Schizophrenia research  2013;144(1-3):87-92.
This study aimed to validate the Computerized UCSD Performance-Based Skills Assessment (C-UPSA), a newly developed scale for assessing functional capacity in patients with schizophrenia.
The C-UPSA was administered to 21 middle-aged and older adults with schizophrenia and 20 healthy comparison (HC) subjects. Schizophrenia participants also completed the original UPSA and a symptom inventory (during a separate visit), and cognitive functioning was assessed in both groups using a brief neuropsychological screening battery.
The C-UPSA total score was significantly correlated with UPSA total scores, and the magnitude of the correlation was comparable to the test-retest reliability of the original UPSA. The C-UPSA was also significantly correlated with UPSA-Brief scores and neuropsychological status among schizophrenia participants. Furthermore, the schizophrenia group scored significantly lower than the HCs on the C-UPSA. ROC curves were generated to determine the optimal C-UPSA value for discriminating between the two groups, with results indicating an optimal cutoff of 75, which is consistent with the derived cutoff from the original UPSA. The C-UPSA identified persons with schizophrenia with 95% accuracy.
The C-UPSA appears to be highly related to the original UPSA. It has several advantages over the standard version, including increased portability, decreased administration time, and minimization of examiner impact on participant performance. Future research would benefit from establishing this test as a clinical and research tool to effectively assess functional capacity.
PMCID: PMC3572290  PMID: 23375625
schizophrenia; computerized assessment; neuropsychology; functioning; rehabilitation; recovery
3.  Rorschach Measures of Cognition Relate to Everyday and Social Functioning in Schizophrenia 
Psychological assessment  2012;25(1):253-263.
Neurocognitive impairment and negative symptoms contribute to functional disability in people with schizophrenia. Yet, a high level of unexplained variability remains after accounting for the role of these factors. This study examined the role of thought disorder, psychological complexity, and interpersonal representations, as measured by the Rorschach, in explaining functional and social skills capacity in 72 middle-aged and older outpatients with schizophrenia (mean age = 51.2). Participants responded to the Rorschach administered using the R-Optimized administration instructions and scored using the Rorschach Performance Assessment System. Relationships with neuropsychological performance and psychopathology were also explored. Psychological complexity, which refers to a person’s cognitive capacity for problem-solving and organizing their surroundings, was correlated with functional capacity (r = .30) and social skills capacity (r = .34). Healthy interpersonal representations were correlated with positive social skills (r’s = .24 to .28). In multiple regression models, psychological complexity accounted for significant variation in functional (β = 0.23, p = 0.02) and social skills capacity (β = 0.35, p < 0.01) after controlling for neurocognitive functioning and psychopathology. These data suggest that psychological complexity plays a significant role in the functional limitations seen in schizophrenia, above and beyond the contributions of neurocognitive impairment and negative symptoms. Support was also found for the impact of healthy object relations functioning with social functioning. Clinical implications include novel information for future development of cognitive remediation treatment strategies based on a patient’s developmental level of psychological capacity and healthy interpersonal schemas.
PMCID: PMC3578027  PMID: 23148650
functional capacity; Rorschach Performance Assessment System; thought disorder; psychological complexity; interpersonal representations
4.  Factors associated with experiences of stigma in a sample of HIV-positive, methamphetamine-using men who have sex with men 
Drug and alcohol dependence  2012;125(1-2):154-159.
While methamphetamine users report high rates of internalized or self-stigma, few studies have examined experiences of stigma (i.e., stigmatization by others) and its correlates.
This study identified correlates of stigma experiences in a sample of 438 HIV-positive men who have sex with men (MSM) who were enrolled in a sexual risk reduction intervention in San Diego, CA.
Approximately 96% of the sample reported experiences of stigma related to their use of methamphetamine. In multiple regression analysis, experiences of stigma were associated with binge use of methamphetamine, injection drug use, increased anger symptoms, reduced emotional support, and lifetime treatment for methamphetamine use.
These findings suggest that experiences of stigma are common among methamphetamine users and that interventions to address this type of stigma and its correlates may offer social, psychological, and health benefits to HIV-positive methamphetamine-using MSM.
PMCID: PMC3419298  PMID: 22572209
Stigma experiences; Methamphetamine; Men who have sex with men; HIV
5.  Identifying the HIV Transmission Bridge: Which Men Are Having Unsafe Sex with Female Sex Workers and with Their Own Wives or Steady Partners? 
To gain insights into bridging behaviors and their correlates among male clients of female sex workers (FSWs).
Men aged ≥18 years who recently paid or traded for sex with FSWs were recruited in Tijuana in 2008–2009. Participants underwent interviews and testing for HIV, chlamydia, syphilis, and gonorrhea. Logistic regression compared “bridgers” (clients who had unprotected sex with FSWs and with a wife or steady partner) with men who did not.
Of 383 men, 134 (35%) had a steady partner. Half (n = 70) of those had unprotected sex with both FSWs and the steady partner. Prevalence of any STI or HIV was 16.5% among bridgers and 2.3% among non-bridgers. Compared to other clients, bridgers were more likely to use drugs during sex with FSWs (81.4% versus 46.9%, p < 0.0001), had higher sensation-seeking (p < 0.0001) and misogyny scores (p = 0.05), and were more likely to offer FSWs extra money for unprotected sex (34.4% versus 1.6%, p < 0.0001). Factors independently associated with bridging were: using drugs during sex with FSWs (adjusted odds ratio (AOR): 3.4, p = 0.007), sensation-seeking (AOR: 4.3 per unit increase, p = 0.05), and offering FSWs more money for unprotected sex (AOR: 24.5, p = 0.003).
Sensation-seeking clients who use drugs during sex and coerce FSWs into unprotected sex may be less responsive to standard risk reduction interventions. Interventions are needed that target clients rather than rely on FSWs to change behaviors that may not be under their control.
PMCID: PMC3392412  PMID: 22481603
male clients; bridging behavior; female sex workers; HIV transmission; prevention; Mexico
6.  Efficacy of a brief behavioral intervention to promote condom use among female sex workers in Tijuana and Ciudad Juarez, Mexico 
American journal of public health  2008;98(11):2051-2057.
To examine efficacy of a brief behavioral intervention to promote condom use among female sex workers (FSWs) in two Mexico-U.S. border cities.
924 FSWs aged ≥18 years without known HIV infection living in Tijuana and Ciudad Juarez having recent unprotected sex with clients were randomized to a 30 minute behavioral intervention integrating motivational interviewing and principles of behavior change, or a didactic control condition. At baseline and six months, women underwent interviews and testing for HIV, syphilis, gonorrhea and chlamydia.
Comparing intervention versus control groups, we observed a 40% decline in cumulative STI incidence (p=0.049). Incidence density for the intervention vs. control was 13.8 vs 24.92 per 100 person years (py) for STIs combined (p=0.034), and 0 vs. 2.01 per 100 py for HIV (p<0.001), with concomitant increases in total numbers and percentages of protected sex acts and decreases in total numbers of unprotected sex acts with clients (p<0.05).
This brief behavioral intervention shows promise in reducing HIV/STI risk behaviors among FSWs in two Mexican-U.S border cities, and may be transferable to other resource-constrained settings.
PMCID: PMC2633868  PMID: 18799768
sex work; prostitute; HIV; sexually transmitted infections; condoms; Mexico
7.  Mother-son relationship as a risk factor for depressive symptoms among methamphetamine users 
Journal of substance use  2012;17(1):51-60.
Retrospective reports of children’s relationships with their parents have been associated with increased risk for depressive symptoms in adulthood. This study examined four dimensions of the current mother-child relationship (affection, criticism, over-involvement, conflict) in relation to depressive symptoms in a sample of 270 HIV-positive men who have sex with men (MSM). Depressive symptoms were positively associated with overt conflict or disagreement with mothers and perceived over-involvement by mothers, and inversely related to frequency of contact with mothers. These findings suggest that clinicians who treat HIV-positive methamphetamine-using MSM with depressive symptoms should evaluate issues in the mother-son relationship and consider family-based therapies as an adjunct to treatment.
PMCID: PMC3609666  PMID: 23543903
depressive symptoms; methamphetamine; men who have sex with men; HIV; maternal relationship
8.  Association between Hospice Care and Psychological Outcomes in Alzheimer's Spousal Caregivers 
Journal of Palliative Medicine  2013;16(11):1450-1454.
Dementia care giving can lead to increased stress, physical and psychosocial morbidity, and mortality. Anecdotal evidence suggests that hospice care provided to people with dementia and their caregivers may buffer caregivers from some of the adverse outcomes associated with family caregiving in Alzheimer's Disease (AD).
This pilot study examined psychological and physical outcomes among 32 spousal caregivers of patients with AD. It was hypothesized that caregivers who utilized hospice services would demonstrate better outcomes after the death of their spouse than caregivers who did not utilize hospice.
The charts of all spousal caregivers enrolled in a larger longitudinal study from 2001 to 2006 (N=120) were reviewed, and participants whose spouse had died were identified. Of these, those who received hospice care (n=10) were compared to those who did not (n=22) for various physiological and psychological measures of stress, both before and after the death of the care recipient. An Analysis of Covariance (ANCOVA), with postdeath scores as the dependent variable and pre-death scores as covariates, was used for all variables.
Significant group differences were found in postdeath depressive symptoms (HAM-D; F(1,29)=6.10, p<0.05) and anxiety symptoms (HAM-A; F(1,29)=5.71, p<0.05). Most psychological outcome variables demonstrated moderate effect sizes with a Cohen's d of>0.5 between groups.
These data suggest that hospice enrollment may ameliorate the detrimental psychological effects in caregivers who have lost a spouse with Alzheimer's Disease. Based on these pilot data, further prospective investigation is warranted.
PMCID: PMC3822398  PMID: 24093721
9.  Correlates of Trading Sex for Methamphetamine in a Sample of HIV-Negative Heterosexual Methamphetamine Users 
Journal of psychoactive drugs  2011;43(2):79-88.
While many studies have examined correlates of trading sex for money, few have examined factors associated with exclusive trading of sex for drugs. We identified sociodemographic, behavioral, and psychological correlates of trading sex for methamphetamine in a sample of HIV-negative heterosexual men and women who were enrolled in a sexual risk reduction intervention in San Diego, California. Of 342 participants, 26% overall (21% of males and 31% of females) reported trading sex for methamphetamine in the past two months. Multiple logistic regression analysis revealed that recently trading sex for methamphetamine was independently associated with being female, homeless, binging on methamphetamine, sexual victimization in the past two months, engaging in anal sex 24 or more times in the past two months, and higher sexual compulsivity scores. Effective interventions for this high-risk population should consider gender-focused counseling for sexual abuse, motivational enhancement therapy, social-cognitive skills training, as well as enhanced access and utilization of social services, including drug treatment.
PMCID: PMC3506393  PMID: 21858954
sex trading; methamphetamine; heterosexual; sexual risk behavior
10.  Drug assertiveness and sexual risk-taking behavior in a sample of HIV-positive, methamphetamine-using men who have sex with men 
Drug assertiveness skills have been demonstrated effective in reducing substance use behaviors among patients with alcohol- or heroin-use disorders. This study examined the association between drug assertiveness and methamphetamine use, psychological factors, and sexual risk behaviors in a sample of 250 HIV-positive men who have sex with men (MSM) enrolled in a safer sex intervention in San Diego, CA. Less assertiveness in turning down drugs was associated with greater frequency and larger amounts of methamphetamine use, lower self-esteem, higher scores on a measure of sexual sensation-seeking, and greater attendance at risky sexual venues. These data suggest that drug assertiveness training should be incorporated into drug abuse treatment programs and other risk reduction interventions for methamphetamine users.
PMCID: PMC3154402  PMID: 21550758
drug assertiveness behavior; methamphetamine; sexual risk behavior; men who have sex with men; HIV-positive
11.  Context matters: The moderating role of bar context in the association between substance use during sex and condom use among male clients of female sex workers in Tijuana, Mexico 
AIDS and behavior  2013;17(8):2577-2587.
Tijuana is situated on Mexico’s northern border with the U.S., where sex work is quasi-legal. Whereas previous work has focused on the risk behaviors of female sex workers (FSWs), less is known about the risk behaviors of their male clients. Further, research has not examined structural factors as moderators of the association between substance use and condom use, including the contexts in which sex takes place. The purpose of the current study is to examine whether having sex with FSWs in a bar moderates the link between alcohol intoxication during sex and condom use. We recruited 375 male clients of FSWs in Tijuana, Mexico from San Diego, California and Tijuana. Using computer assisted interviewing, we surveyed participants on their alcohol use, condom use, and physical contexts of sex with FSWs in the past four months. Results showed that more frequent intoxication during sex with FSWs is associated with more unprotected sex, but only among clients having sex with FSWs in a bar context. Results point to potential reasons for inconsistent condom use with FSWs in this context, including lower risk perceptions of sex with FSWs in bars. Future research should examine structural factors that underlie clients’ risk behavior in bars in order to inform structural-level HIV prevention interventions.
PMCID: PMC3778075  PMID: 23640653
HIV risk; male clients; female sex workers; alcohol use; risk environment; structural interventions
12.  A Randomized Clinical Trial of Behavioral Activation (BA) Therapy for Improving Psychological and Physical Health in Dementia Caregivers: Results of the Pleasant Events Program (PEP) 
Behaviour research and therapy  2013;51(10):623-632.
Dementia caregiving is associated with elevations in depressive symptoms and increased risk for cardiovascular diseases (CVD). This study evaluated the efficacy of the Pleasant Events Program (PEP), a 6-week Behavioral Activation intervention designed to reduce CVD risk and depressive symptoms in caregivers. One hundred dementia family caregivers were randomized to either the 6-week PEP intervention (N=49) or a time-equivalent Information-Support (IS) control condition (N=51). Assessments were completed pre- and post-intervention and at 1-year follow-up. Biological assessments included CVD risk markers Interleukin-6 (IL-6) and D-dimer. Psychosocial outcomes included depressive symptoms, positive affect, and negative affect. Participants receiving the PEP intervention had significantly greater reductions in IL-6 (p=.040), depressive symptoms (p=.039), and negative affect (p=.021) from pre- to post-treatment. For IL-6, clinically significant improvement was observed in 20.0% of PEP participants and 6.5% of IS participants. For depressive symptoms, clinically significant improvement was found for 32.7% of PEP vs 11.8% of IS participants. Group differences in change from baseline to 1-year follow-up were non-significant for all outcomes. The PEP program decreased depression and improved a measure of physiological health in older dementia caregivers. Future research should examine the efficacy of PEP for improving other CVD biomarkers and seek to sustain the intervention’s effects.
PMCID: PMC3774137  PMID: 23916631
Depression; Cardiovascular Disease; Alzheimer’s Disease; Intervention; Treatment
13.  Direct and Mediated Effects of Cognitive Function with Multidimensional Outcome Measures in Schizophrenia: The Role of Functional Capacity 
Although cognitive ability is a known predictor of real-world functioning in schizophrenia, there has been an expanded interest in understanding the mechanisms by which it explains real-world functioning in this population. We examined the extent to which functional capacity (i.e., skills necessary to live independently) mediated the relationship between cognitive ability and both observer and self-reported real-world functioning in 138 outpatients with schizophrenia. Functional capacity significantly mediated the relations between cognitive ability and observer rated real world functioning, but not self-reported real world functioning, with small to medium effect sizes observed for all outcomes. The role of cognitive ability in observer vs. self-reported real-world functioning may be explained by different mechanisms.
PMCID: PMC3789849  PMID: 23984631
Functioning; Impairment; Cognition; Self-report; Observer report
16.  The course of vocational functioning in patients with schizophrenia: Re-examining social drift 
Vocational functioning is markedly impaired in people with schizophrenia. In addition to low rates of employment, people with schizophrenia have been reported to be underachieved compared to other family members. Among the causes of this vocational impairment may be cognitive deficits and other skills deficits, as well as social factors impacting on opportunities for employment. In this study, we examined two separate samples of people with schizophrenia who differed in their educational and social backgrounds. We compared personal and maternal education in people with schizophrenia attending an outpatient rehabilitation facility (n = 57) or receiving outpatient services at a VA medical center (n = 39). The sample as a whole showed evidence of decline in vocational status from their best job to their most recent job. Patients attending a rehabilitation facility had completed less education than their mothers, while the VA patients completed more. Differences between personal and maternal education predicted the difference in status between best and latest jobs in the sample as a whole. VA patients were more likely to be living independently and performed better on a measure of functional capacity than the rehabilitation sample. These data implicate vocational decline in schizophrenia and also suggest that this decline may originate prior to the formal onset of the illness. At the same time, vocational outcomes appear to be related to social opportunities.
PMCID: PMC4171044  PMID: 25254157
Schizophrenia; Employment; Education; Cognition
17.  Social and Behavioral Characteristics of HIV-positive MSM Who Trade Sex for Methamphetamine 
Previous research among drug-using men who have sex with men (MSM) indicates that trading sex for methamphetamine may be common.
This study identified background characteristics, substance use variables, contextual factors, and sexual risk behaviors associated with trading sex for methamphetamine in a sample of HIV-positive MSM. Baseline data were gathered from 155 participants who were enrolled in a sexual risk-reduction intervention. Logistic regression was used to compare MSM who traded sex for methamphetamine with men who did not.
Forty-three percent of the sample reported trading sex for methamphetamine in the past 2 months. Trading sex for methamphetamine was associated with being a binge user, homelessness, having an income of less than $20,000 per year, being less assertive at turning down drugs, engaging in more anal sex without a condom, and seeking out risky sex partners when high on methamphetamine.
Conclusions and Scientific Significance
These data suggest that the trading of sex for methamphetamine may be a primary source of new HIV infections within and outside of the MSM community, necessitating targeted interventions with this vulnerable subgroup.
PMCID: PMC3383823  PMID: 20955106
methamphetamine; trading sex; men who have sex with men; sexual risk behavior
18.  “Over here, it’s just drugs, women and all the madness”: The HIV risk environment of clients of female sex workers in Tijuana, Mexico 
Social science & medicine (1982)  2011;72(7):1185-1192.
HIV vulnerability depends upon social context. Based in broader debates in social epidemiology, political economy, and sociology of health, Rhodes’ (2002) “risk environment” framework provides one heuristic for understanding how contextual features influence HIV risk, through different types of environmental factors (social, economic, policy, and physical) which interact at different levels of influence (micro, macro). Few data are available on the “risk environment” of male clients of female sex workers (FSWs); such men represent a potential “bridge” for transmission of HIV and other sexually transmitted infections from high- to low-prevalence populations. Using in-depth interviews (n=30), we describe the HIV risk environment of male clients in Tijuana, Mexico, where disproportionately high HIV prevalence has been reported among FSWs and their clients. A number of environmental themes influence risky sex with FSWs and the interplay between individual agency and structural forces: social isolation and the search for intimacy; meanings and identities ascribed to Tijuana’s Zona Roja (red light district) as a risky place; social relationships in the Zona Roja; and economic roles. Our findings suggest that clients’ behaviors are deeply embedded in the local context. Using the HIV “risk environment” as our analytic lens, we illustrate how clients’ HIV risks are shaped by physical, social, economic, and political factors. The linkages between these and the interplay between structural- and individual-level experiences support theories that view structure as both enabling as well as constraining. We discuss how the “embeddedness” of clients’ experiences warrants the use of environmental interventions that address the circumstances contributing to HIV risk at multiple levels.
PMCID: PMC3075317  PMID: 21414702
sex work; prostitution; clients; HIV; social determinants; structural factors; risk environment; Mexico
19.  Drug-using male clients of female sex workers who report being paid for sex: HIV/STI, demographic and drug use correlates 
Sexually transmitted diseases  2013;40(8):10.1097/OLQ.0b013e31829569ec.
Research has focused on male clients of female sex workers (FSWs) and their risk for HIV/STIs. Yet, it is unclear whether the commercial sex behaviors of these men are limited to paying for sex, or whether they may also be paid for sex themselves.
We analyzed interview data and HIV/STI test results from 170 drug-using male clients of FSWs in Tijuana, Mexico, to determine the extent to which these men report being paid for sex and the association with positive HIV/STI results.
Over one-quarter of men reported having been paid for sex in the past four months. In a multivariate logistic regression model, reporting having been paid for sex was significantly associated with testing positive for any HIV/STI (Adjusted Odds Ratio [AdjOR] 3.53, 95% C.I. 1.33–9.35), being bisexual (AdjOR 15.59, 95% C.I. 4.81–50.53), injection drug use in the past four months (AdjOR 2.65, 95% C.I. 1.16–6.03), and cocaine use in the past four months (AdjOR 2.93, 95% C.I. 1.22–7.01).
Findings suggest that drug-using male clients of FSWs may be characterized by unique risk profiles that require tailored HIV prevention interventions.
PMCID: PMC3829783  PMID: 23863514
HIV transmission; male clients; female sex workers; drug use; Mexico
20.  Injection Drug Use as a Mediator between Client-perpetrated Abuse and HIV Status among Female Sex Workers in Two Mexico-U.S. Border Cities 
AIDS and behavior  2009;15(1):179-185.
We examined relationships between client-perpetrated emotional, physical, and sexual abuse, injection drug use, and HIV-serostatus among 924 female sex workers (FSWs) in Tijuana and Ciudad (Cd.) Juarez, two large Mexico-U.S. border cities. We hypothesized that FSWs’ injection drug use would mediate the relationship between client-perpetrated abuse and HIV-seropositivity. The prevalence of client-perpetrated emotional, physical, and sexual abuse in the past 6 months was 26%, 18%, and 10% respectively; prevalence of current injection drug use and HIV was 12% and 6%, respectively. Logistic regression analyses revealed that client-perpetrated sexual abuse was significantly associated with HIV-seropositivity and injection drug use, and that injection drug use was positively associated with HIV-seropositivity. Injection drug use partially mediated the relationship between client-perpetrated sexual abuse and HIV-seropositivity. Results suggest the need to address client-perpetrated violence and injection drug use when assessing HIV risk among FSWs.
PMCID: PMC2889005  PMID: 19636697
female sex workers; client-perpetrated abuse; injection drug use; HIV
21.  Relations between personal mastery, chronic caregiving stress, and multiple dimensions of fatigue 
A substantial proportion of chronically stressed informal caregivers of Alzheimer’s disease patients report experiencing fatigue. The objective of this study was to examine whether personal mastery moderates the relationship between caregiving status (caregiver/non-caregiver) and multiple dimensions of fatigue.
Seventy-three elderly Alzheimer’s caregivers and 41 elderly non-caregivers completed the short form of the Multidimensional Fatigue Symptom Inventory (MFSI-SF) and questionnaires assessing mastery.
Regression analyses indicate that global fatigue scores were significantly higher for caregivers (M = 38.0 ± 21.0) compared to non-caregivers (M = 18.2 ± 10.4). However, personal mastery moderated the relations between caregiving status and global fatigue (t = −2.03, df = 107, p = .045), such that for those with low mastery, caregivers’ fatigue scores were 18.1 points higher than non-caregivers, and for those with high mastery, this difference was only 7.5 points. For specific dimensions of fatigue, mastery moderated the relations between caregiving status and both Emotional (t = −2.01, df = 107, p = .047) and Physical (t = −2.51, df = 107, p = .014) fatigue. Specifically, association between caregiving status and emotional fatigue was greater when mastery was low than when mastery was high. In regards to physical fatigue, caregiving status was significantly associated with physical fatigue when mastery was low, but was not when mastery was high. Significant main effects were found between mastery and general fatigue and vigor.
Given the high proportion of caregivers who experience fatigue and the impact that fatigue can have on health; these findings provide important information regarding mastery’s relationship with fatigue and may potentially inform interventions aiming to alleviate fatigue in caregivers.
PMCID: PMC4091958  PMID: 19548267
Alzheimer’s Disease; Caregiving; Fatigue; Control; Coping; Exhaustion
22.  When Functional Capacity and Real-World Functioning Converge: The Role of Self-Efficacy 
Schizophrenia Bulletin  2012;39(4):908-916.
Although functional capacity is typically diminished, there is substantial heterogeneity in functional outcomes in schizophrenia. Motivational factors likely play a significant role in bridging the capacity-to-functioning gap. Self-efficacy theory suggests that although some individuals may have the capacity to perform functional behaviors, they may or may not have confidence they can successfully perform these behaviors in real-world settings. We hypothesized that the relationship between functional capacity and real-world functioning would be moderated by the individual’s self-efficacy in a sample of 97 middle-aged and older adults with schizophrenia (mean age = 50.9 ± 6.5 years). Functional capacity was measured using the Brief UCSD Performance-based Skills Assessment (UPSA-B), self-efficacy with the Revised Self-Efficacy Scale, and Daily Functioning via the Specific Level of Functioning (SLOF) scale and self-report measures. Results indicated that when self-efficacy was low, the relationship between UPSA-B and SLOF scores was not significant (P = .727). However, when self efficacy was high, UPSA-B scores were significantly related to SLOF scores (P = .020). Similar results were observed for self-reported social and work functioning. These results suggest that motivational processes (ie, self-efficacy) may aid in understanding why some individuals have the capacity to function well but do not translate this capacity into real-world functioning. Furthermore, while improvement in capacity may be necessary for improved functioning in this population, it may not be sufficient when motivation is absent.
PMCID: PMC3686440  PMID: 22328642
functioning; psychosis; motivation; control; recovery
23.  Pleasant Events, Activity Restriction, and Blood Pressure in Dementia Caregivers 
A combination of high engagement in pleasurable activities and low perceived activity restriction is potentially protective for a number of health and quality of life outcomes. This study tests the newly proposed Pleasant Events and Activity Restriction (PEAR) model to explain level of blood pressure (BP) in a sample of elderly dementia caregivers.
This cross-sectional study included 66 caregivers, ≥ 55 years of age, providing in-home care to a relative with dementia. Planned comparisons were made to assess group differences in BP between caregivers reporting high engagement in pleasant events plus low perceived activity restriction (HPLR; N = 22) to those with low pleasure plus high restriction (LPHR; N = 23) or those with either high pleasure plus high restriction or low pleasure plus low restriction (HPHR/LPLR; N = 21).
After adjustments for age, sex, body mass index, use of anti-hypertensive medication, physical activity, and number of health problems, HPLR participants (86.78 mm Hg) had significantly lower mean arterial pressure compared to LPHR participants (94.70 mm Hg) (p = .01, Cohen’s d=0.89) and HPHR/LPLR participants (94.84 mm Hg) (p = .023, d=0.91). Similar results were found in post-hoc comparisons of both systolic and diastolic BP.
This study extends support for the PEAR model to physical health outcomes. Differences in BP between the HPLR group and other groups were of large magnitude and thus clinically meaningful. The findings may inform intervention studies aimed at investigating whether increasing pleasant events and lowering perceived activity restriction may lower BP.
PMCID: PMC3572271  PMID: 22888824
Alzheimer’s disease; dementia caregiving; behavioral activation; coping; elderly
24.  The Factor Structure of Neurocognition and Functional Capacity in Schizophrenia: A Multidimensional Examination of Temporal Stability 
Although neurocognition is commonly described in terms of different functional domains, some factor analytic studies have suggested a simpler dimensional structure for neuropsychological (NP) tests in patients with schizophrenia. Standardized tasks of everyday functioning, or tests of “functional capacity” (FC), are viewed differently from traditional NP tests, and are hence used as a co-primary measure in treatment studies. However, FC and NP tests have been found to be highly correlated. In fact, a recent study of ours suggested that performances on these different types of tasks constituted a single latent trait in a cross-sectional analysis. The current study examined the longitudinal factor structure of a combined set of NP and FC tests. Patients with schizophrenia (n=195) were examined at two assessment occasions separated by periods ranging from 6 weeks to 6 months. Participants were assessed with the MATRICS Consensus Cognitive Battery (MCCB) and two performance-based assessments of FC. A single latent trait was extracted using full information maximum likelihood procedures, and its temporal stability was examined in terms of: stability of the latent trait scores, the intercorrelations of the three indicators of the latent trait, and the stability of loadings for the FC and NP items underlying the latent trait at the two measurement occasions. All indices of temporal stability were confirmed, with stability not related to follow-up duration. Variation in clinical symptoms and treatments across the measurement occasions was negligible. These findings raise the question of whether cognitive abilities measured by NP tests and FC instruments are tapping a single ability construct, which might have shared causal influences as well.
PMCID: PMC3825700  PMID: 23425725
Neuropsychology; Disability; Latent Traits; Longitudinal Studies; Functional capacity; Linear models
25.  Psychosexual and social-cognitive correlates of sexual risk behavior among male clients of female sex workers in Tijuana, Mexico 
AIDS care  2010;22(12):1473-1480.
Male clients of female sex workers (FSWs) may act as a bridge to the general population contributing to the spread of HIV and other sexually transmitted infections in the United States and Mexico. This study used cross-sectional data to identify psychosexual and social cognitive factors associated with sexual risk behavior in a bi-national sample of 300 male clients of FSWs recruited in Tijuana, Mexico from June to October, 2008. In a multiple regression analysis, the number of unprotected vaginal sex acts with FSWs was associated with higher sexual compulsivity scores, lower self-efficacy for condom use, greater use of illicit drugs, and more financial need. Behavioral interventions are urgently needed to assist clients of FSWs in reducing high-risk behaviors in an effort to prevent the spread of HIV/STIs in this high-risk population and their sexual partners.
PMCID: PMC3082496  PMID: 21154035
male clients; female sex workers; sexual risk behavior; U.S.- Mexico border

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