These guides were designed to help us understand any changes in our variables of interest and how they influenced self-management behaviors.Data analysis of the qualitative and quantitative data occurred at the same time, but were not integrated until both types of data were analyzed. In analyzing the quantitative data, we first assessed the distribution of all quantitative variables . We summarized baseline characteristics by using means, standard deviations, medians, interquartile ranges, and counts and percentages of women by substance use group , depending on the variable’s distribution. We used GEEs with an identity link function and an unstructured correlation structure to describe how social capital and substance use influences HIV self-management across the three time points. Separate models were fit for each HIV self-management outcome. In addition to the effect of social capital and substance use, we examined independent effects of age, discrimination, and traumatic events by adding these covariates to GEE models. All statistical analyses were conducted using Stata 14.0 with p values < .05 considered statistically significant. Qualitative data were managed using the qualitative data analysis program Dedoose and was analyzed by the research team using qualitative description methodology . Data were transcribed and examined by two research team members who coded the data using the constant comparative method, identifying patterns and themes . These team members met regularly during coding to discuss consistencies and inconsistencies in the data. A priori codes related to social capital, substance use, and self-management based on our literature review were initially applied, and then inductive codes were applied. Transcripts were revisited in a series of iterative steps to confirm coding classification and that theoretical saturation was reached. Variations on the themes and negative cases were identified to help understand the full range of data within codes.
A final codebook of themes, definitions,mobile grow systems and exemplar codes was created to aid analysis. Data were coded and analyzed using Dedoose version 8.0.42 . Study procedures are presented consistent with the Good Reporting of a Mixed Methods Study standards .Foundational to trust was the women’s communities and how the community could support or damage that trust. Many described their community as neighborly, “My neighborhood is a community, a family community. [There are] a lot of animals, people stay to themselves but say ‘hi, how you doing?’ We’re neighborly.” The community offered tangible resources to help women take care of their health needs. “I go to community meals once a month and see the same people there each time.” Less tangible but equally important was how community comes together and transmits information that helps WLHIV recover from their addictions. When describing a vigil held by her community to commemorate a tragedy, one woman said, “When you riding down the street and see a telephone pole with teddy bears, signs, and balloons, it makes you think . . . it [reminds] me of the things I was doing in the past, drugs and stuff.” By helping confer a sense of identity, the provision of resources, and ultimately value, a woman’s community can influence her trust, which can affect her self-management behavior. But some WLHIV reported detrimental aspects of her community, including safety, noise, and recently moving into a new neighborhood. For example, a WLHIV was hesitant to access her community resources because of perceived safety threats. “There is a community center but I don’t go there. I’m terrified because it’s a lot of guys who just hang out . . . .” Others did not feel the community helped improve health behaviors and described unhealthy community norms. “[To deal with hard times], my community gets high.” In these cases, community was still influential but in a way that did not promote healthy behaviors.In our mixed methods study examining the influence of social capital on HIV self-management among WLHIV, we observed that social capital is important for self-management, and we were able to integrate new qualitative data on how social capital does this.
Social capital has consistently been linked to improved health outcomes among adults living with HIV, but what has been missing from the literature is how it does that. Our quantitative data are consistent with this literature and clearly demonstrate that better social capital is associated with better self-management in WLHIV. Yet by qualitatively examining the components of social capital in-depth, we describe how three key components of social capital can improve HIV self-management in this population–trust as a powerful yet scarce resource, a WLHIV’s community directly influences that trust, and having a strong value of self. Each of these components required that WLHIV actively and positively engage with their social network. However, for women trying to overcome a substance addiction, this can be particularly challenging since aspects of her social network can trigger substance use either directly or via social capital mechanisms we describe. Furthermore, being identified as a current or former substance user may fracture existing social networks or prevent WLHIV from being more connected to their community, which could influence their access to certain types of social capital. Our qualitative data suggest that rebuilding a strong social network, one that enhances trust in others and in oneself, increases engagement with her community, and ultimately helps a WLHIV believe in her value as a person. Our data also provide insight into how nurses can help enhance social capital in this population, including having members of the health care team spend the time necessary to earn and keep the trust of WLHIV. Our quantitative data suggest that such efforts may help to improve HIV self-management behavior in this population. Recently, investigators described the importance of building trust in HIV care and engagement over time . Our data support those findings and highlight that the long-term trust-building process is critical for those living with chronic HIV infection, and perhaps this process may be even more critical among highly vulnerable populations. However, our qualitative data also reveal other ways to improve social capital, and obtain the benefits derived from it, that are more challenging to implement.Whether offering tangible goods, information, kindness, or effective use of the school infrastructure, our participants derived much-needed resources from their community, which led to an increased sense of value. This increased sense of value motivated WLHIV to engage in HIV self-management behaviors to help improve their health. These data suggest that continuing to advocate for policies and resources to connect neighbors to one another and emphasizing our similarities can help improve the health of WLHIV. We also found quantitative evidence that WLHIV face challenges to engaging in HIV self-management that may be influenced by recent traumatic events. While this is consistent with other studies that highlight that levels of trauma exposure influence HIV outcomes, lifetime trauma is also ubiquitous in this population. In high-resource settings, such as ours, trauma and interpersonal violence are estimated to be experienced by 68% to 95% of WLHIV .
Recognizing the influence of trauma on poor health outcomes in WLHIV and recognizing that trauma can be successfully treated,cannabis grow supplies clinicians and advocates are adopting trauma-informed care models for HIV care. Trauma-informed care models emphasize that both the clinician’s and the individual’s recognition of and response to trauma and create an environment that is safe and empowering for WLHIV . Our quantitative and qualitative data suggest that promoting social capital both within the clinic setting and in the community may temper the negative impact of trauma and provide previously untapped avenues for addressing substance use with WLHIV. However, we also found differences between our findings and existing literature. A key difference is that we did not find diminished HIV medication adherence between current and previous substance users. Substance use is considered one of the main barriers to achieving higher rates of viral suppression when an HIV diagnosis is established . The use of different substances in individuals with HIV is associated with lower antiretroviral therapy adherence , increased missed clinic visits , and decreased knowledge of HIV status . This previous research suggests that fundamental resources such as money, time, and energy will mainly be used to acquire and use substances with little attention directed to self-care. While we observed a relationship between substance use and global HIV self-management, we did not observe a relationship between substance use and HIV medication adherence. There are several possible explanations for this. First, the field of HIV has done a phenomenal job of teaching all PLHIV of the primary need to take HIV medications every day. As the medications have improved and many PLHIV are taking one HIV medication once a day, it has gotten easier to adhere to these medications. So despite many WLHIV facing personal and structural barriers to HIV medication adherence, the importance of adherence coupled with simplified regimens may help them overcome these barriers. In addition, our sample of volunteer participants is small, and though we saw a negative effect of substance use on HIV medication adherence, our study may have been under powered to detect a statistically significance effect. In addition to our small sample size, there are several other limitations that should be considered. First, all WLHIV were recruited from a single site in the Midwestern United States. The demographics and substance use patterns of our sample limit generalizability of our findings. We also did not use member checking to help enhance the rigor of our findings. However, we tried to overcome these limitations by employing several strategies including triangulating both qualitative and quantitative data, having prolonged engagement between the community of WLHIV and research team, and having multiple team members engaged in our data integration. Integration of quantitative data with our rich qualitative data led to new insights into how social capital can be fostered among WLHIV and how it can be used to overcome challenges faced by them. This would not have been possible without data integration. In conclusion, social capital was associated with better HIV self-management and HIV medication adherence over time, perhaps offsetting the negative effects of substance use. Social capital increased trust, fostering a strong sense of community, and helped WLHIV feel valued. These findings enhance understanding of how nurses can support WLHIV who are addicted to illicit substances and to help them maintain sobriety and improve their HIV self-management.The epidemic of vaping-related acute lung injury is a public health disaster. As of October 3, 2019, the CDC had received reports of 1,080 lung injury cases from 48 states and one U.S. territory, with 18 deaths confirmed in 15 states . Almost 80% of the cases are younger than 34 years of age, with 38% younger than 21 years. Many, but not all, of the cases involved vaping of products containing tetrahydrocannabinol . The research letter by Triantafyllou and colleagues in this issue of the Journal describes the features of six cases seen this past summer at the University of Pittsburgh Medical Center . The cases are emblematic of those reported to the CDC. They were young men who presented with respiratory and gastrointestinal complaints who reported regular use of vaporized cannabis and nicotine products. The patients showed evidence of a systemic inflammatory response with leukocytosis, and chest imaging showed bilateral, multi-focal ground-glass opacifications. The patients were treated with antibiotics until cultures came back as negative, and most patients received corticosteroids. Two of the patients required mechanical ventilation. Fortunately, no one died. The case descriptions from the University of Pittsburgh team are similar to those of a larger case series published earlier this year . One common finding in the two published case series is the prevalence of use of a cannabis product known as “Dank Vape.” What are Dank Vapes? According to the CDC, Dank Vapes are the most prominent in a class of largely counterfeit brands, with common packaging that is easily available online and used by distributors to market THC-containing cartridges . Public health officials in Wisconsin and Illinois, two of the states hit hardest by the vaping-related acute lung injury epidemic, interviewed 86 patients, and 66% said they had used THC products labeled as Dank Vapes .