Critique Paper Part 2
Estefania Ureña
New York City College of Technology
NUR 3130-E716
December 8, 2015
The study The Intersection of Violence, Substance Use, Depression, and STDs addressed the patients of sexually transmitted disease clinics who were of low socioeconomic status and are racial minorities which held a high prevalence of psychosocial and health problems. Through previous research the study recognizes variables such as childhood abuse, intimate partner violence, depression, and substance abuse co-occur with risky sexual behavior. The purpose of this study was to further establish if the interrelatedness of these co-occurrences proposes a syndemic. A syndemic requiring the interaction of these co-occurring conditions resulting in the worsening of health effects.
Problem and Purpose
     The problem statement was clearly stated in the study The Intersection of Violence, Substance Use, Depression, and STDs, “High rates of psychosocial and health problems have been identified among patients attending sexually transmitted disease (STD) clinics, who are disproportionately urban, low-income, and racial/ethnic minorities” (Senn et al., p 614). The study describes the high correlation and prevalence of psychosocial problems as in substance abuse, partner, violence, and child abuse among the patients of the STD clinic which opens the possibility of a synergistic relationship. But according to previous studies the additive effects rather than the interactive effects of psychosocial problems on risk of STDs have been investigated. Senn, Carey, and Vanable state their purpose as, “This study sought to determine whether these problems co-occurred, and whether they indicated the presence of a syndemic” (p 614).
This study state the variables as they test a potential interactive relationship, “(the count of psychosocial/health problems endorsed) as the independent variable and (a) multiple partners and (b) STD diagnosis as the dependent variables” (Senn et al., p 616). This study does carry significance for the field of nursing as this study addresses the strong association and occurrences of psychosocial problems and STDs requires the attention of health care providers and a unique opportunity to further research the underlying factor of these comorbid conditions.
Method
The research conducted by the study utilized a randomized controlled trial for the participants which is appropriate for the purpose of this research as explained by Polit & Beck, “In particular, experimental designs (randomized controlled trials or RCTs) are the best possible designs for illuminating causal relationships” (p 152). Participants were eligible for the RCT dependent on the following conditions: 18 years old and older, partaken in sexual risky behavior in the last three months, willing to take HIV test, and give informed consent. Biases are minimized through the process of randomization, “if people are randomly assigned, there is no systematic bias in the groups with regard to attributes that may affect the dependent variable” (Polit & Beck p 154).
Participants had to complete multiple computerized surveys based on the predictors associated with risk of STDs as in childhood, sexual abuse, depressive symptoms, substance abuse and intimate partner violence over the span of three months. Also, in those three months participants were asked the number of sexual partners and their STD status determined by reviewal of electronic medical records.
Population and Sample
The study sufficiently describes the population by identifying the participants they were studying who attended the STD clinic with high occurrences of psychosocial issues as, “disproportionately urban, have low income, and are racial/ethnic minorities” (Senn, et al. p 614). A sample of 1557 patients was collected from a publicly funded walk-in clinic. The sample was clearly described with the following demographics, “The sample was 46% female (n = 719), and 64% African American (n = 1003). The average age of participants was 29.2 years (SD = 9.6 years), and most were single (78%; n = 1213). More than one-half of the sample was unemployed (51%; n = 796); 62% had a high school education or less (n = 967), and 56% reported an income of < $15,000 per year (n = 875)” (Senn, et al. p 615).
The sample size was large and diverse which is beneficial to the study as a small size can be a hindrance as expressed by Coughlan, “the size of a sample is also important in quantitative research as small samples are at risk of being overly representative of small subgroups within the target population” (p 660).
SummaryÂ
The study thus far designates the prevalence between its indicators and the increased likelihood of increased risky sexual behavior and diagnosis of a sexually transmitted disease but is working on its way to establish a synergistic relationship between its variables where a worsening effect is present in light of its already present association.
Procedures
There were no stated interventions within this study. Participants were made up patients attending the STD clinic who were recruited in a randomized controlled trial helping to minimize bias in the selection of participants. The staff that collected the data was skilled as it was a trained research assistant who screened the patients for eligibility and obtained consent from those who choose to participate and the permission to review their medical records. Patients were then instructed to complete surveys on various psychosocial and health conditions.
Data Collection and Measurement
Key variables within this study were operationalized using the best methods. The specific instruments used to measure the key variables were described sufficiently and were adequate choices for the measures being assessed. Being that these psychosocial problems and health conditions consist of a high prevalence with increased risky sexual behavior and STD diagnosis they are categorized as predictors. The participants were instructed to complete computerized surveys asking questions based on the predictors.
The data collection methods provided data that was consistent in its reliability and validity. Childhood sexual abuse (CSA) used items based on sexual activities experienced before the ages of 13-16 with someone 5-10 years older and the experiences of force or coercion before age 17, “Participants classified as having experienced CSA based on responses to these questions reported higher rates of adult sexual risk behavior, supporting validity of the questions” (Senn et al., p 616). To evaluate the depressive symptoms amongst the patients the study used The Center for Epidemiologic Studies Depression Scale (CESD) to see how often they were sad during a week ranging from rarely, some, occasionally, to most of the time, “previous research has found good internal consistency reliability and validity for the CESD” (Senn et al., p 616). As the study by Shrier et al points out the high prevalence of depression and sexual risk behavior, “Depressed individuals may also use sexual risk behaviors as part of a coping response to their depressive symptoms. Research has suggested that men, in particular, tend to purposively turn their attention away from depressive symptoms and onto neutral or pleasant activities, such as sexual intercourse”.
Binge drinking was assessed by seeing in the past 3 months which participants had 5 or more drink on one occasion, “This measure of binge drinking is associated with more alcohol related problems, supporting its validity” (Senn et al., p 616).  Participants who answered anything besides “never” in regards to marijuana use were classified as users, “We chose this classification because research has found that any marijuana use, regardless of the level of use, was associated with sexual risk behavior” (Senn et al., p 616). Participants who reported being physically harmed, threatened, or isolated from life activities by a current or sexual partner were considered to have experienced intimate partner violence.
Results
The study used odds ratios to determine the relatedness between the health problems and sexually risky behavior and STD diagnosis. This helped illustrate the interrelatedness between the psychosocial problems themselves as occurrences of CSA, IPV, and depression were associated with higher odds of binge drinking and marijuana use. Along with a strong association between the predictors was an increase of outcomes. As specific predictors like binge drinking and marijuana use raised the odds of multiple sex partners while CSA, depression, or marijuana use were more likely to have a STD diagnosis, “Overall, participants with a substance use disorder were 70% more likely than those without a substance use disorder to have a current STD and were 2 to 3 times more likely to have multiple sexual partners or be inconsistent condom users. These findings are consistent with other studies of young persons that demonstrate an association between alcohol and marijuana use and risky sexual behaviors and STDs” (Cook, et al. p. 568).
To establish an additive effect of health problems on the sexual risk behavior and STD diagnosis Senn et al used logistic regressions with the independent variables being the number of psychosocial and health problems and the STD diagnosis and multiple sex partners being the dependent variables. This study chose an appropriate method as logistic regressions is a multivariable method used to examine the relationships between multiple independent variables and a categorical dependent variable (Polit & Beck p 240). It was established with each additional psychosocial problem sanctioned by the participant it increased the odds of multiple sex partners being reported. Also, to verify an interactive effect between the psychosocial predictors and the probability of a STD diagnosis logistic regressions with pairwise interactions was used which showed the percentage of an STD diagnosis amongst the participants at 31% of those who reported both CSA and recent marijuana use and 30% reporting both CSA and IPV (Senn et al. p. 617)
It was made clear that the hypothesis was supported as the odds ratios depicted the interrelatedness between the predictors as they co-occurred as well as their strong association on the outcomes of increased multiple sex partners and the increased likelihood of being diagnosed with a STD. Senn et al had also depicted a syndemic with not only a co-occurrence of psychosocial predictors but a worsening of outcomes with the increase of a diagnosis of an STD which is also agreed upon in other studies, “…consistent with previous research, experiencing childhood abuse was associated with a greater likelihood of also experiencing relationship abuse, and both childhood abuse and post-traumatic stress disorder were positively associated with being diagnosed with a sexually transmitted infection and/or HIV. Altogether, these results suggest that HIV prevention programs should work to address a broad spectrum of psychosocial problems, including abuse, mental health problems, and substance use. These problems not only co-occur, they may also operate to exacerbate one another and have a compounding effect on HIV infection risk” (Pitpitan, et al. p. 10).
Summary Assessment
The limitations stated by this study was their restriction of time and lack of in depth interviewing with the use of only brief screenings they weren’t able to fully identify all psychosocial conditions effected by the STD clinic participants. Even though this study was a first of its kind trying to prove a syndemic theory with the interaction of the psychosocial predictors they did meet their key criteria as logistic regressions of pairwise interactions expressed the worsening outcome of increased STD diagnosis when participants endorsed CSA along with marijuana use or IPV. The incidence of having multiple psychosocial conditions had a high correlation as did reporting having more psychosocial predictors magnify the probability of being diagnosed with a STD and having more than 1 sexual partner. The findings of this study do appear to be valid and hold truth to the values of their results as, “This pattern of findings is consistent with prior research among STD clinic patients and has sometimes been interpreted as reflecting a syndemic” (Senn et al. p. 618).
This study provides a unique opportunity as the patients of this STD clinic have a variety of psychosocial and health conditions it provides health providers a brief window to counsel the patients on changing their behavior as the patients may be more susceptible to motivation as they apprehensively wait for their STD results. For many of these patients visits to a STD clinic might be their only access to health care so providing them with multiple services for mental health, substance use counseling, prenatal care or HIV prevention and care may help lessen the likelihood of sexual risk behavior. This study does provide meaningful evidence for the nursing practice as these STD clinic patients face not only health, behavioral, and substance use problems it provides the chance for practitioners from various disciplines to screen, assess, prevent and treat multiple health and psychosocial problems with a true multidisciplinary approach (Senn et al., p 619).
References
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