Description
Due 04/19/19
One of the many reasons social workers conduct needs assessment is to provide support for new programs. Social workers have many methods available to collect necessary data for a needs assessment.
Social workers can use existing data from a wide range of sources, including local and national reports by government and nonprofit agencies, as well as computerized mapping resources. Social workers can gather new data through interviews and surveys with individuals and focus groups. This data can provide the evidence that supports the need for the program.
To prepare for this Assignment, review the needs assessment plans that you and your classmates generated for this week’s Discussion. Also, review the logic models that you created in Week 7 and any literature on needs of caregivers that you used to generate them. Consider the following to stimulate your thinking:
- Getting information about the needs of the target population:
- Who would informants be?
- What is your purpose for interacting with them?
- What questions would you ask?
- What method would you use (interview, focus group, questionnaire)?
- Finding potential clients:
- Who would informants be?
- What is your purpose for interacting with them?
- What questions would you ask?
- What method would you use?
- Interacting with the target population:
- Who would informants be?
- What is your purpose for interacting with them?
- What questions would you ask?
- What method would you use?
By Day 7
Submit a 2- to 3-page paper outlining a hypothetical needs assessment related to the support group program for caregivers. Include the following:
- The resources needed to operate this service
- The program activities
- The desired outcomes
- A plan for gathering information about the population served
- Justifications for your plans and decisions
- A one-paragraph conclusion describing how you might conduct a follow-up to the needs assessment at the implementation stage of the program evaluation
References
Dudley, J. R. (2014). Social work evaluation: Enhancing what we do. (2nd ed.) Chicago, IL: Lyceum Books.
- (For review) Chapter 6, “Needs Assessment” (pp. 107–142)
- Chapter 7, “Crafting Goals and Objectives” (pp. 144–164)
Document:Tutty,L.M., & Rothery, M.A. (2010). Needs assessments. In B. Thyer (Ed.), The handbook of social work research methods (2nd ed., pp- 149-162). Thousand Oaks, CA: Sage. (PDF)
Stewart, K. E., Phillips, M. M., Walker, J. F., Harvey, S. A., & Porter, A. (2011). Social services utilization and need among a community sample of persons living with HIV in the rural south. AIDS Care, 23(3), 340–347.
Walter, H. J., Gouze, K., Cicchetti, C., Arend, R., Mehta, T., Schmidt, J., & Skvarla, M. (2011). A pilot demonstration of comprehensive mental health services in inner-city public schools. Journal of School Health, 81(4), 185–193.
Note: Retrieved from the Walden Library databases.
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AIDS Care
Vol. 23, No. 3, March 2011, 340347
Social services utilization and need among a community sample of persons living with HIV
in the rural south
Katharine E. Stewart, Martha M. Phillips, Jada F. Walker*, Sarah A. Harvey and Austin Porter
Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, USA
(Received 7 December 2009; final version received 16 June 2010)
HIV prevalence has increased faster in the southern USA than in other areas, and persons living with HIV
(PLWHIV) in the south are often rural, impoverished, or otherwise under-resourced. Studies of urban PLWHIV
and those receiving medical care suggest that use of social services can enhance quality of life and some medical
outcomes, but little is known about patterns of social service utilization and need among rural southern
PLWHIV. The AIDS Alabama needs assessment survey, conducted in 2007, sampled a diverse community cohort
of 476 adult PLWHIV representative of the HIV-positive population in Alabama (66% male, 76% Black, and
26% less than high school education). We developed service utilization/need (SUN) scores for each of 14 social
services, and used regression models to determine demographic predictors of those most likely to need each
service. We then conducted an exploratory factor analysis to determine whether certain services clustered together
for the sample. Case management, assistance obtaining medical care, and financial assistance were most
commonly used or needed by respondents. Black respondents were more likely to have higher SUN scores for
alcohol treatment and for assistance with employment, housing, food, financial, and pharmacy needs;
respondents without spousal or partner relationships had higher SUN scores for substance use treatment.
Female respondents were more likely to have higher SUN scores for childcare assistance. Black respondents and
unemployed respondents were more likely to have SUN scores in the highest quartile of the overall score
distribution. Factor analysis yielded three main factors: basic needs, substance use treatment, and legal/medical
needs. These data provide important information about rural southern PLWHIV and their needs for ancillary
services. They also suggest clusters of service needs that often occur among PLWHIV, which may help case
managers and other service providers work proactively to identify important gaps in care.
Keywords: HIV; health services utilization; rural; south; need
Introduction
The prevalence of HIV infection has increased
rapidly in the southern USA compared to the other
areas of the country (Foster, 2007; Reif, Geonnotti,
& Whetten, 2006) and southern states are among
those with the highest AIDS-related death rates in the
country (Reif, Geonnotti, et al., 2006; Whetten &
Reif, 2006). For example, in 2006, Alabama had an
age-adjusted HIV mortality rate of 4.2 per 100,000
persons, compared to 4.0 per 100,000 persons in the
USA (Heron et al., 2009). Several issues in the south
have been considered as possible contributors to the
increased incidence of HIV and AIDS in the region,
including high rates of sexually transmitted infections
(STIs), racial disparities, the conservative culture of
the south, poverty, and lack of access to health
insurance and health care (Krawczyk, Funkhouser,
Kilby, & Vermund, 2006; Luciano, 2002).
These factors create barriers to treatment for
persons living with HIV (PLWHIV), but the majority of this research has been conducted in major
*Corresponding author. Email: jfwalker@uams.edu
ISSN 0954-0121 print/ISSN 1360-0451 online
# 2011 Taylor & Francis
DOI: 10.1080/09540121.2010.507743
http://www.informaworld.com
urban areas and these findings are not always
applicable to the southern population (Krawczyk
et al., 2006). For example, the HIV Cost and Service
Utilization Study (HCSUS) estimates that 46% of
PLWHIV in the USA have an annual household income of less than US$10,000, that 63% are
unemployed and 20% have no health insurance
(McKinney & Marconi, 2002). These estimates
are relatively consistent with observations of clinical
cohorts of PLWHIV, but may underestimate the
significant needs for social services among PLWHIV
in certain areas of the country, including the rural
south, where the proportion of uninsured adults
often approaches or exceeds 25%.
A lack of economic and social resources compromises a person’s ability to access health care services,
and research supports the finding that many southern
PLWHIV are disproportionally underresourced and
thus require considerably more assistance for everyday activities and basic services, such as housing
assistance, emergency provisions, support groups,
AIDS Care 341
mental health-related counseling, legal assistance, and
financial assistance (Reif, Geonnotti, et al., 2006;
Reif, Whetten, Lowe, & Ostermann, 2006; Whetten &
Reif, 2006). Reif and colleagues studied infectious
disease clinics throughout the south, and found that
84.5% of the patients with HIV who were served by
these clinics needed at least one support service, with
47% reporting that at least one need was not met
(Reif, Whetten, et al., 2006).
Given that, in urban samples of PLWHIV, lack
of access to social services is not only related to
general quality of life (Chin, Botsko, Behar, &
Finkelstein, 2009), but is also closely tied to medical
adherence, access to medical treatment, and health
outcomes (Messeri, Abramson, Aidala, Lee, & Lee,
2002; Reif, Whetten, et al., 2006), it is crucial to
understand more about the social service needs of
people living with HIV/AIDS in the south. Since a
sizable proportion of southern PLWHIV is not
engaged with a medical care provider (McKinney
& Marconi, 2002), surveys of social service needs
that are limited to samples of HIV-positive patients
or only urban PLWHIV may provide an incomplete
picture of the experience of PLWHIV in rural or
southern communities.
Community-based surveys may provide a more
comprehensive description of the patterns of social
service utilization and need in this population. One
particularly valuable approach to reaching this community is through AIDS Service Organizations
(ASOs) which are staffed by individuals who are
well known and trusted by the community of
PLWHIV, and provide social services that are otherwise limited or unavailable (Tolle, 2009). Understanding the patterns of service needs and utilization
among these community populations may be helpful
to providers and case managers in working proactively with their clients.
AIDS Alabama is an ASO located in Birmingham,
Alabama that has been funded since 1988 by HRSA,
CDC, HUD, state, local, and private resources. It
serves a catchment area that includes approximately
16,000 PLWHIV, and coordinates with other ASOs
throughout the state. To understand the priority
needs of its client population, AIDS Alabama conducted statewide surveys of PLWHIV in 1999, 2003,
and 2007.
We examined the 2007 AIDS Alabama Needs
Assessment Survey data to explore patterns of service
utilization and needs, expecting that a high proportion of respondents would report utilization of or
need for services across multiple domains, and that
several services would ‘‘cluster’’ together.
Methods
Participants
AIDS Alabama and partner agencies recruited
PLWHIV to be as representative as possible of the
adult PLWHIV population, in terms of geographical
distribution and racial and gender balance; participants were recruited from most Alabama counties.
However, in some instances, certain counties remained underrepresented in the sample due to a low
known HIV-positive population. Attempts were
made to include individuals who both were and
were not well-connected to health care, by working
through ASOs, case managers, and other HIVpositive individuals, who were able to identify and
refer sporadic users of ASO services and those not
receiving medical care.
Measures
This survey was created specifically to assess the
needs and concerns of the adult PLWHIV population
for the use of AIDS Alabama staff in program
planning, and as such was not originally developed
for research purposes. It was jointly developed by
AIDS Alabama and Columbia University School of
Public Health faculty in 1999. The survey content was
slightly edited by consultants at the University of
Alabama at Birmingham for 2003 and again for 2007
but similar collection methods were used in all survey
administrations. In addition to standardized measures on aspects of living with HIV, the interview
covered demographics; basic needs such as food,
transportation, and housing; and a wide range of
other ancillary services. A total of 14 basic and
ancillary service needs were included: financial,
legal, pharmaceutical, employment, and housing
assistance; substance use, mental health, and alcohol
treatment; medical services, transportation, dental
care, case management, food, and childcare. Respondents were asked to indicate whether they had
received services or had needed assistance in the
past 6 months in each of these areas.
Procedures
Survey questionnaires were administered by trained
interviewers who were HIV-positive Alabamians.
Interviewers traveled to meet and conduct the survey
at a convenient location for the participant, usually at
an ASO or HIV clinic office or meeting room where
privacy could be assured. All information collected
was confidential, assigned a unique identification
number, and free of identifying personal information.
Some interviews were video- or audio-taped with the
342 K.E. Stewart et al.
participant’s written permission. Each recording was
securely stored without personal information. The
interview took approximately one hour to administer.
Participants did receive US$15 compensation for
their time, travel, and effort.
Results
Data analysis approach
The 2007 survey was administered to 525 communitydwelling individuals. A total of 29 individuals who
identified with a racial/ethnic group other than Black
or White or had missing data for racial/ethnic group
and 20 individuals who identified themselves as
transgender or had missing gender data were excluded for comparison purposes, which resulted in
476 individuals included in subsequent analyses.
Descriptive analyses were completed to obtain the
characteristics of this sample.
Binary service utilization/need (SUN) variables
were created for each of the services included in the
survey. If the respondent indicated either that s/he was
receiving services of a specific type or had needed that
service then a value of 1 was assigned to the service/
utilization variable; if the respondent indicated that
they had not received the service and had not needed
it, then a value of 0 was assigned. This combined SUN
variable approach reflected the overall demand for
each service by including those who have already
gained access to the service as well as those who
needed the service but were not able to obtain it.
Descriptive univariate analyses were completed to
determine the number and percentage of respondents
who reported using or needing each service, and
demographic characteristics were compared for those
who had an individual SUN variable score and those
who had missing data for that variable. No significant
differences were noted for any of these comparative
analyses. Subsequently, multivariate linear regression
analyses described the characteristics of individuals
most likely to need or use each service. Logistic
regression models included each SUN as the outcome
variable. Predictor variables in each model included:
race, gender, age, relationship status, education,
having children in the home, and employment status.
Next, values for the individual SUN variables
were summed to create an overall SUN score for each
respondent. A total of 367 respondents had complete
data for each of the SUN variables and thus a
calculated overall SUN score. Descriptive univariate
analyses were completed to characterize the pattern
of overall SUN scores; again, demographic characteristics were compared for those with and without an
overall score. No substantial differences between
groups were identified. Multivariate linear regression
analyses described the characteristics of individuals
who were evidenced the highest and lowest SUN
scores (defined as those respondents in the highest
and lowest quartiles of overall SUN scores, respectively). The outcome variable was the overall SUN
score and predictor variables were included as
described above.
Then SUN variables were subjected to an exploratory factor analysis using squared multiple correlations as prior communality estimates. The principal
factor method was used to extract the factors. We used
both oblique and orthogonal rotation of factors;
because the results were essentially identical, the
orthogonal rotation results are reported. A threefactor solution was hypothesized; factor selection was
based on eigenvalues (]1.0), scree plot, and interpretability were considered in confirming factors.
Items were considered to load on a factor if the
rotated factor loading was greater than or equal to
0.35 on one factor and less than 0.35 on other factors.
Demographics of the sample
The characteristics of the analysis sample are summarized in Table 1. The majority of survey respondents were black males between the ages of 40 and
64 years. The average age was 42.5 years (standard
deviation (SD), 9.84). The youngest was 18 years and
the oldest 76 years of age. A majority were single or
never married. Approximately, one in four respondents had children in the home, one in three had some
college education, and one in four reported having less
than a high school diploma. Just fewer than 70%
reported being employed either full or part time.
Frequency of service utilization/need (SUN)
Services used or needed by the survey respondents
are summarized in Table 2. The most commonly
used or needed services included case management,
medical assistance, and financial counseling. The
least needed or used services were childcare, legal
assistance, alcohol treatment, and employment assistance. Approximately, half of the respondents indicated that they either needed or were receiving
mental health services, transportation assistance, and
housing assistance.
Demographic group associations with service
utilization/need (SUN)
Table 3 summarizes findings regarding the demographic subgroups most likely to report using or
needing services, by type of service. Regression
AIDS Care 343
Table 1. Demographic characteristics of analysis sample, AIDS Alabama 2007 analysis sample (n 476).
Characteristic
n
%
Gender
Male
Female
314
162
66.0
34.0
Racial/ethnic group
White
Black
112
364
23.5
76.5
Age
1839 years
40 years and older
165
309
34.8
65.1
Education
Less than high diploma
High school diploma or higher
Children in home
121
339
116
26.3
73.7
25.4
83
391
17.5
94.0
139
69.8
334
142
70.2
29.8
206
60.6
Relationship
Living with life partner or spouse
Not living with partner (widowed, married but
separated, divorced, never married)
Employed
Income
Less than US$800 a month
US$800 a month or more
Unemployed and receiving
SSI, SSDI or disability income
analyses indicated no significant differences among
groups in their likelihood of needing or using medical
or legal assistance. Black respondents were more
likely to be users of alcohol treatment, employment,
financial, food, housing, and pharmacy assistance
than were their white counterparts. Individuals not
living with a partner or a spouse were more likely to
be using or need substance use treatment services
than respondents in partnered relationships. Women
were more likely than men to be users of childcare
assistance, as were individuals with children in the
home, compared to individuals without children in
the home. Furthermore, compared to respondents
who were employed, respondents who were not
working were more likely to be users of a number
of services, including: case management, mental
Table 2. Types of services needed and/or used by survey respondents, AIDS Alabama 2007 (n 476).
Services needed or used
Alcohol treatment
Case management
Child care
Dental care
Drug treatment
Employment
Financial counseling
Food
Housing
Legal assistance
Medical assistance
Pharmacy assistance
Mental health counseling
Transportation
n
%
107
426
21
302
164
115
389
338
272
74
428
310
242
262
23.2
93.8
4.5
64.9
34.9
24.5
83.1
71.9
58.0
16.3
90.3
71.6
52.0
55.3
344 K.E. Stewart et al.
Table 3. Results of regression analyses to identify high-risk groups by assistance type, AIDS Alabama 2007.
Risk group
Adjusted odds ratioa
95% confidence interval
p-Value
Assistance type
Alcohol treatment
Case management
Child care
Dental care
Drug treatment
Employment
Financial counseling
Food assistance
Housing assistance
Legal assistance
Medical assistance
Pharmacy assistance
Mental health
counseling
Transportation
assistance
Black
Female
Older age
Less
education
Children in
home
Not
partnered
Not
working
1.9
1.0, 3.5
0.0499
1.6
0.7, 3.9
0.2794
0.9
0.2, 3.6
0.9187
1.6
1.0, 2.5
0.0656
1.0
0.6, 1.5
0.8910
2.7
1.4, 5.4
0.0043
3.2
1.7, 6.2
0.0003
3.1
1.9, 5.1
B0.0001
1.6
1.0, 2.5
0.0643
1.2
0.6, 2.2
0.6797
1.3
0.6, 2.6
0.5383
1.8
1.1, 3.0
0.0187
0.6
0.4, 1.0
0.0738
1.2
0.7, 1.9
0.5649
1.4
0.9, 2.4
0.1558
1.2
0.5, 3.2
0.6506
4.1
1.4, 12.4
0.0125
1.2
0.7, 1.9
0.4837
1.0
0.7, 1.6
0.8778
0.9
0.5, 1.5
0.6671
1.5
0.8, 3.0
0.2446
0.8
0.5, 1.3
0.3266
1.5
1.0, 2.3
0.0758
0.7
0.4, 1.4
0.3373
0.9
0.5, 1.9
0.8133
0.8
0.5, 1.3
0.4399
1.3
0.8, 1.9
0.2941
1.3
0.8, 2.0
0.3320
1.1
0.6, 1.8
0.8141
0.9
0.4, 2.2
0.8585
0.5
0.2, 1.4
0.1840
1.0
0.6, 1.6
0.9842
0.9
0.6, 1.4
0.6595
0.7
0.5, 1.2
0.2379
1.0
0.6, 1.9
0.9131
1.2
0.7, 1.9
0.5172
0.8
0.5, 1.3
0.3419
1.5
0.8, 2.8
0.1816
1.7
0.9, 3.3
0.1184
0.8
0.5, 1.3
0.3169
0.9
0.6, 1.4
0.7388
0.9
0.6, 1.4
0.5363
0.7
0.4, 1.2
0.1697
1.2
0.5, 2.9
0.6232
1.6
0.6, 4.5
0.3921
0.7
0.5, 1.1
0.1531
0.9
0.6, 1.3
0.5538
1.5
0.9, 2.4
0.1425
0.9
0.5, 1.7
0.8470
1.2
0.8, 2.0
0.3487
1.1
0.7, 1.6
0.7698
0.9
0.5, 1.6
0.6998
1.4
0.8, 2.7
0.2784
0.9
0.6, 1.5
0.8139
1.2
0.8, 1.8
0.3265
1.1
0.7, 1.6
0.7811
0.6
0.3, 1.1
0.1046
1.7
0.5, 5.6
0.3695
4.6
1.5, 13.6
0.0068
1.0
0.6, 1.7
0.8830
0.7
0.4, 1.3
0.2650
1.1
0.6, 1.8
0.6534
1.0
0.5, 2.2
0.9477
0.9
0.5, 1.5
0.5844
1.2
0.7, 1.9
0.5057
1.1
0.6, 2.2
0.7343
1.8
0.7, 4.3
0.1962
0.8
0.5, 1.4
0.5036
1.3
0.8, 2.1
0.3320
1.1
0.7, 1.8
0.7552
1.9
0.09, 3.9
0.0953
0.8
0.3, 2.6
0.7717
1.4
0.4, 5.1
0.6519
1.0
0.6, 1.8
0.9504
2.4
1.3, 4.6
0.0053
1.2
0.6, 2.3
0.5648
1.2
0.6, 2.4
0.6737
0.9
0.5, 1.7
0.8153
1.1
0.7, 1.9
0.7107
1.3
0.6, 2.8
0.4881
1.0
0.4, 2.3
0.9510
0.7
0.4, 1.3
0.2791
0.9
0.5, 1.5
0.5849
1.4
0.8, 2.4
0.2563
0.7
0.4, 1.2
0.2091
4.2
1.8, 9.8
0.0008
2.2
0.7, 7.5
0.1747
1.7
1.1, 2.7
0.0177
1.0
0.6, 1.5
0.8734
1.0
0.6, 1.8
0.8624
11.9
6.4, 22.2
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AIDS Care
Vol. 23, No. 3, March 2011, 340347
Social services utilization and need among a community sample of persons living with HIV
in the rural south
Katharine E. Stewart, Martha M. Phillips, Jada F. Walker*, Sarah A. Harvey and Austin Porter
Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, USA
(Received 7 December 2009; final version received 16 June 2010)
HIV prevalence has increased faster in the southern USA than in other areas, and persons living with HIV
(PLWHIV) in the south are often rural, impoverished, or otherwise under-resourced. Studies of urban PLWHIV
and those receiving medical care suggest that use of social services can enhance quality of life and some medical
outcomes, but little is known about patterns of social service utilization and need among rural southern
PLWHIV. The AIDS Alabama needs assessment survey, conducted in 2007, sampled a diverse community cohort
of 476 adult PLWHIV representative of the HIV-positive population in Alabama (66% male, 76% Black, and
26% less than high school education). We developed service utilization/need (SUN) scores for each of 14 social
services, and used regression models to determine demographic predictors of those most likely to need each
service. We then conducted an exploratory factor analysis to determine whether certain services clustered together
for the sample. Case management, assistance obtaining medical care, and financial assistance were most
commonly used or needed by respondents. Black respondents were more likely to have higher SUN scores for
alcohol treatment and for assistance with employment, housing, food, financial, and pharmacy needs;
respondents without spousal or partner relationships had higher SUN scores for substance use treatment.
Female respondents were more likely to have higher SUN scores for childcare assistance. Black respondents and
unemployed respondents were more likely to have SUN scores in the highest quartile of the overall score
distribution. Factor analysis yielded three main factors: basic needs, substance use treatment, and legal/medical
needs. These data provide important information about rural southern PLWHIV and their needs for ancillary
services. They also suggest clusters of service needs that often occur among PLWHIV, which may help case
managers and other service providers work proactively to identify important gaps in care.
Keywords: HIV; health services utilization; rural; south; need
Introduction
The prevalence of HIV infection has increased
rapidly in the southern USA compared to the other
areas of the country (Foster, 2007; Reif, Geonnotti,
& Whetten, 2006) and southern states are among
those with the highest AIDS-related death rates in the
country (Reif, Geonnotti, et al., 2006; Whetten &
Reif, 2006). For example, in 2006, Alabama had an
age-adjusted HIV mortality rate of 4.2 per 100,000
persons, compared to 4.0 per 100,000 persons in the
USA (Heron et al., 2009). Several issues in the south
have been considered as possible contributors to the
increased incidence of HIV and AIDS in the region,
including high rates of sexually transmitted infections
(STIs), racial disparities, the conservative culture of
the south, poverty, and lack of access to health
insurance and health care (Krawczyk, Funkhouser,
Kilby, & Vermund, 2006; Luciano, 2002).
These factors create barriers to treatment for
persons living with HIV (PLWHIV), but the majority of this research has been conducted in major
*Corresponding author. Email: jfwalker@uams.edu
ISSN 0954-0121 print/ISSN 1360-0451 online
# 2011 Taylor & Francis
DOI: 10.1080/09540121.2010.507743
http://www.informaworld.com
urban areas and these findings are not always
applicable to the southern population (Krawczyk
et al., 2006). For example, the HIV Cost and Service
Utilization Study (HCSUS) estimates that 46% of
PLWHIV in the USA have an annual household income of less than US$10,000, that 63% are
unemployed and 20% have no health insurance
(McKinney & Marconi, 2002). These estimates
are relatively consistent with observations of clinical
cohorts of PLWHIV, but may underestimate the
significant needs for social services among PLWHIV
in certain areas of the country, including the rural
south, where the proportion of uninsured adults
often approaches or exceeds 25%.
A lack of economic and social resources compromises a person’s ability to access health care services,
and research supports the finding that many southern
PLWHIV are disproportionally underresourced and
thus require considerably more assistance for everyday activities and basic services, such as housing
assistance, emergency provisions, support groups,
AIDS Care 341
mental health-related counseling, legal assistance, and
financial assistance (Reif, Geonnotti, et al., 2006;
Reif, Whetten, Lowe, & Ostermann, 2006; Whetten &
Reif, 2006). Reif and colleagues studied infectious
disease clinics throughout the south, and found that
84.5% of the patients with HIV who were served by
these clinics needed at least one support service, with
47% reporting that at least one need was not met
(Reif, Whetten, et al., 2006).
Given that, in urban samples of PLWHIV, lack
of access to social services is not only related to
general quality of life (Chin, Botsko, Behar, &
Finkelstein, 2009), but is also closely tied to medical
adherence, access to medical treatment, and health
outcomes (Messeri, Abramson, Aidala, Lee, & Lee,
2002; Reif, Whetten, et al., 2006), it is crucial to
understand more about the social service needs of
people living with HIV/AIDS in the south. Since a
sizable proportion of southern PLWHIV is not
engaged with a medical care provider (McKinney
& Marconi, 2002), surveys of social service needs
that are limited to samples of HIV-positive patients
or only urban PLWHIV may provide an incomplete
picture of the experience of PLWHIV in rural or
southern communities.
Community-based surveys may provide a more
comprehensive description of the patterns of social
service utilization and need in this population. One
particularly valuable approach to reaching this community is through AIDS Service Organizations
(ASOs) which are staffed by individuals who are
well known and trusted by the community of
PLWHIV, and provide social services that are otherwise limited or unavailable (Tolle, 2009). Understanding the patterns of service needs and utilization
among these community populations may be helpful
to providers and case managers in working proactively with their clients.
AIDS Alabama is an ASO located in Birmingham,
Alabama that has been funded since 1988 by HRSA,
CDC, HUD, state, local, and private resources. It
serves a catchment area that includes approximately
16,000 PLWHIV, and coordinates with other ASOs
throughout the state. To understand the priority
needs of its client population, AIDS Alabama conducted statewide surveys of PLWHIV in 1999, 2003,
and 2007.
We examined the 2007 AIDS Alabama Needs
Assessment Survey data to explore patterns of service
utilization and needs, expecting that a high proportion of respondents would report utilization of or
need for services across multiple domains, and that
several services would ‘‘cluster’’ together.
Methods
Participants
AIDS Alabama and partner agencies recruited
PLWHIV to be as representative as possible of the
adult PLWHIV population, in terms of geographical
distribution and racial and gender balance; participants were recruited from most Alabama counties.
However, in some instances, certain counties remained underrepresented in the sample due to a low
known HIV-positive population. Attempts were
made to include individuals who both were and
were not well-connected to health care, by working
through ASOs, case managers, and other HIVpositive individuals, who were able to identify and
refer sporadic users of ASO services and those not
receiving medical care.
Measures
This survey was created specifically to assess the
needs and concerns of the adult PLWHIV population
for the use of AIDS Alabama staff in program
planning, and as such was not originally developed
for research purposes. It was jointly developed by
AIDS Alabama and Columbia University School of
Public Health faculty in 1999. The survey content was
slightly edited by consultants at the University of
Alabama at Birmingham for 2003 and again for 2007
but similar collection methods were used in all survey
administrations. In addition to standardized measures on aspects of living with HIV, the interview
covered demographics; basic needs such as food,
transportation, and housing; and a wide range of
other ancillary services. A total of 14 basic and
ancillary service needs were included: financial,
legal, pharmaceutical, employment, and housing
assistance; substance use, mental health, and alcohol
treatment; medical services, transportation, dental
care, case management, food, and childcare. Respondents were asked to indicate whether they had
received services or had needed assistance in the
past 6 months in each of these areas.
Procedures
Survey questionnaires were administered by trained
interviewers who were HIV-positive Alabamians.
Interviewers traveled to meet and conduct the survey
at a convenient location for the participant, usually at
an ASO or HIV clinic office or meeting room where
privacy could be assured. All information collected
was confidential, assigned a unique identification
number, and free of identifying personal information.
Some interviews were video- or audio-taped with the
342 K.E. Stewart et al.
participant’s written permission. Each recording was
securely stored without personal information. The
interview took approximately one hour to administer.
Participants did receive US$15 compensation for
their time, travel, and effort.
Results
Data analysis approach
The 2007 survey was administered to 525 communitydwelling individuals. A total of 29 individuals who
identified with a racial/ethnic group other than Black
or White or had missing data for racial/ethnic group
and 20 individuals who identified themselves as
transgender or had missing gender data were excluded for comparison purposes, which resulted in
476 individuals included in subsequent analyses.
Descriptive analyses were completed to obtain the
characteristics of this sample.
Binary service utilization/need (SUN) variables
were created for each of the services included in the
survey. If the respondent indicated either that s/he was
receiving services of a specific type or had needed that
service then a value of 1 was assigned to the service/
utilization variable; if the respondent indicated that
they had not received the service and had not needed
it, then a value of 0 was assigned. This combined SUN
variable approach reflected the overall demand for
each service by including those who have already
gained access to the service as well as those who
needed the service but were not able to obtain it.
Descriptive univariate analyses were completed to
determine the number and percentage of respondents
who reported using or needing each service, and
demographic characteristics were compared for those
who had an individual SUN variable score and those
who had missing data for that variable. No significant
differences were noted for any of these comparative
analyses. Subsequently, multivariate linear regression
analyses described the characteristics of individuals
most likely to need or use each service. Logistic
regression models included each SUN as the outcome
variable. Predictor variables in each model included:
race, gender, age, relationship status, education,
having children in the home, and employment status.
Next, values for the individual SUN variables
were summed to create an overall SUN score for each
respondent. A total of 367 respondents had complete
data for each of the SUN variables and thus a
calculated overall SUN score. Descriptive univariate
analyses were completed to characterize the pattern
of overall SUN scores; again, demographic characteristics were compared for those with and without an
overall score. No substantial differences between
groups were identified. Multivariate linear regression
analyses described the characteristics of individuals
who were evidenced the highest and lowest SUN
scores (defined as those respondents in the highest
and lowest quartiles of overall SUN scores, respectively). The outcome variable was the overall SUN
score and predictor variables were included as
described above.
Then SUN variables were subjected to an exploratory factor analysis using squared multiple correlations as prior communality estimates. The principal
factor method was used to extract the factors. We used
both oblique and orthogonal rotation of factors;
because the results were essentially identical, the
orthogonal rotation results are reported. A threefactor solution was hypothesized; factor selection was
based on eigenvalues (]1.0), scree plot, and interpretability were considered in confirming factors.
Items were considered to load on a factor if the
rotated factor loading was greater than or equal to
0.35 on one factor and less than 0.35 on other factors.
Demographics of the sample
The characteristics of the analysis sample are summarized in Table 1. The majority of survey respondents were black males between the ages of 40 and
64 years. The average age was 42.5 years (standard
deviation (SD), 9.84). The youngest was 18 years and
the oldest 76 years of age. A majority were single or
never married. Approximately, one in four respondents had children in the home, one in three had some
college education, and one in four reported having less
than a high school diploma. Just fewer than 70%
reported being employed either full or part time.
Frequency of service utilization/need (SUN)
Services used or needed by the survey respondents
are summarized in Table 2. The most commonly
used or needed services included case management,
medical assistance, and financial counseling. The
least needed or used services were childcare, legal
assistance, alcohol treatment, and employment assistance. Approximately, half of the respondents indicated that they either needed or were receiving
mental health services, transportation assistance, and
housing assistance.
Demographic group associations with service
utilization/need (SUN)
Table 3 summarizes findings regarding the demographic subgroups most likely to report using or
needing services, by type of service. Regression
AIDS Care 343
Table 1. Demographic characteristics of analysis sample, AIDS Alabama 2007 analysis sample (n 476).
Characteristic
n
%
Gender
Male
Female
314
162
66.0
34.0
Racial/ethnic group
White
Black
112
364
23.5
76.5
Age
1839 years
40 years and older
165
309
34.8
65.1
Education
Less than high diploma
High school diploma or higher
Children in home
121
339
116
26.3
73.7
25.4
83
391
17.5
94.0
139
69.8
334
142
70.2
29.8
206
60.6
Relationship
Living with life partner or spouse
Not living with partner (widowed, married but
separated, divorced, never married)
Employed
Income
Less than US$800 a month
US$800 a month or more
Unemployed and receiving
SSI, SSDI or disability income
analyses indicated no significant differences among
groups in their likelihood of needing or using medical
or legal assistance. Black respondents were more
likely to be users of alcohol treatment, employment,
financial, food, housing, and pharmacy assistance
than were their white counterparts. Individuals not
living with a partner or a spouse were more likely to
be using or need substance use treatment services
than respondents in partnered relationships. Women
were more likely than men to be users of childcare
assistance, as were individuals with children in the
home, compared to individuals without children in
the home. Furthermore, compared to respondents
who were employed, respondents who were not
working were more likely to be users of a number
of services, including: case management, mental
Table 2. Types of services needed and/or used by survey respondents, AIDS Alabama 2007 (n 476).
Services needed or used
Alcohol treatment
Case management
Child care
Dental care
Drug treatment
Employment
Financial counseling
Food
Housing
Legal assistance
Medical assistance
Pharmacy assistance
Mental health counseling
Transportation
n
%
107
426
21
302
164
115
389
338
272
74
428
310
242
262
23.2
93.8
4.5
64.9
34.9
24.5
83.1
71.9
58.0
16.3
90.3
71.6
52.0
55.3
344 K.E. Stewart et al.
Table 3. Results of regression analyses to identify high-risk groups by assistance type, AIDS Alabama 2007.
Risk group
Adjusted odds ratioa
95% confidence interval
p-Value
Assistance type
Alcohol treatment
Case management
Child care
Dental care
Drug treatment
Employment
Financial counseling
Food assistance
Housing assistance
Legal assistance
Medical assistance
Pharmacy assistance
Mental health
counseling
Transportation
assistance
Black
Female
Older age
Less
education
Children in
home
Not
partnered
Not
working
1.9
1.0, 3.5
0.0499
1.6
0.7, 3.9
0.2794
0.9
0.2, 3.6
0.9187
1.6
1.0, 2.5
0.0656
1.0
0.6, 1.5
0.8910
2.7
1.4, 5.4
0.0043
3.2
1.7, 6.2
0.0003
3.1
1.9, 5.1
B0.0001
1.6
1.0, 2.5
0.0643
1.2
0.6, 2.2
0.6797
1.3
0.6, 2.6
0.5383
1.8
1.1, 3.0
0.0187
0.6
0.4, 1.0
0.0738
1.2
0.7, 1.9
0.5649
1.4
0.9, 2.4
0.1558
1.2
0.5, 3.2
0.6506
4.1
1.4, 12.4
0.0125
1.2
0.7, 1.9
0.4837
1.0
0.7, 1.6
0.8778
0.9
0.5, 1.5
0.6671
1.5
0.8, 3.0
0.2446
0.8
0.5, 1.3
0.3266
1.5
1.0, 2.3
0.0758
0.7
0.4, 1.4
0.3373
0.9
0.5, 1.9
0.8133
0.8
0.5, 1.3
0.4399
1.3
0.8, 1.9
0.2941
1.3
0.8, 2.0
0.3320
1.1
0.6, 1.8
0.8141
0.9
0.4, 2.2
0.8585
0.5
0.2, 1.4
0.1840
1.0
0.6, 1.6
0.9842
0.9
0.6, 1.4
0.6595
0.7
0.5, 1.2
0.2379
1.0
0.6, 1.9
0.9131
1.2
0.7, 1.9
0.5172
0.8
0.5, 1.3
0.3419
1.5
0.8, 2.8
0.1816
1.7
0.9, 3.3
0.1184
0.8
0.5, 1.3
0.3169
0.9
0.6, 1.4
0.7388
0.9
0.6, 1.4
0.5363
0.7
0.4, 1.2
0.1697
1.2
0.5, 2.9
0.6232
1.6
0.6, 4.5
0.3921
0.7
0.5, 1.1
0.1531
0.9
0.6, 1.3
0.5538
1.5
0.9, 2.4
0.1425
0.9
0.5, 1.7
0.8470
1.2
0.8, 2.0
0.3487
1.1
0.7, 1.6
0.7698
0.9
0.5, 1.6
0.6998
1.4
0.8, 2.7
0.2784
0.9
0.6, 1.5
0.8139
1.2
0.8, 1.8
0.3265
1.1
0.7, 1.6
0.7811
0.6
0.3, 1.1
0.1046
1.7
0.5, 5.6
0.3695
4.6
1.5, 13.6
0.0068
1.0
0.6, 1.7
0.8830
0.7
0.4, 1.3
0.2650
1.1
0.6, 1.8
0.6534
1.0
0.5, 2.2
0.9477
0.9
0.5, 1.5
0.5844
1.2
0.7, 1.9
0.5057
1.1
0.6, 2.2
0.7343
1.8
0.7, 4.3
0.1962
0.8
0.5, 1.4
0.5036
1.3
0.8, 2.1
0.3320
1.1
0.7, 1.8
0.7552
1.9
0.09, 3.9
0.0953
0.8
0.3, 2.6
0.7717
1.4
0.4, 5.1
0.6519
1.0
0.6, 1.8
0.9504
2.4
1.3, 4.6
0.0053
1.2
0.6, 2.3
0.5648
1.2
0.6, 2.4
0.6737
0.9
0.5, 1.7
0.8153
1.1
0.7, 1.9
0.7107
1.3
0.6, 2.8
0.4881
1.0
0.4, 2.3
0.9510
0.7
0.4, 1.3
0.2791
0.9
0.5, 1.5
0.5849
1.4
0.8, 2.4
0.2563
0.7
0.4, 1.2
0.2091
4.2
1.8, 9.8
0.0008
2.2
0.7, 7.5
0.1747
1.7
1.1, 2.7
0.0177
1.0
0.6, 1.5
0.8734
1.0
0.6, 1.8
0.8624
11.9
6.4, 22.2
B
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