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Linking injection drug users to medical services: role of street outreach referrals.

A traditional role of social workers has been to link disadvantaged community members with service agencies. However, the rise of HIV infection among injection drug users (IDUs) has necessitated the use of indigenous street outreach workers to fulfill this role (Ashery, Davis, Davis, & Ross, 1993). Street outreach workers currently provide a range of services that help prevent the spread of HIV, including risk-reduction messages and instruction; distribution of bleach, condoms, or both; and referrals to medical services (Anderson et al., 1996). Although street outreach is an important means of "reducing and overcoming institutional barriers to health care for disadvantaged groups" (Valentine & Wright-DeAguero, 1996, p. 73), published studies on HIV and social workers have not examined this emerging function of street outreach and its implications for the social work profession. Those studies have focused on three areas of concern: stress and burnout from providing direct services to clients infected with HIV (Bennett, Kelaher, & Ross, 1994; Cushman, Evans, & Namerow, 1995; Wade, Beckerman, & Stein, 1996), challenges faced by practitioners who work directly with people with AIDS (Beckerman & Rock, 1996; Miah, Mizanur, & Ray, 1994; Napoleone, 1988), and social workers' knowledge of and attitudes about AIDS (Knight, 1996; Shi et al., 1993; Stewart & Reppucci, 1994).

Most published studies on street outreach and IDUs have focused on risk behavior (Anderson et al., 1996; Birkel et al., 1993; Wechsberg, Smith, & Harris-Adeeyo, 1992) or the operations of community-based outreach projects (Abdul-Quader et al., 1992; Broadhead & Heckathorn, 1994). As a result, there is only limited knowledge of the relationship between street outreach referrals and IDUs' acting on those referrals. Two studies suggest that street outreach workers have been able to persuade IDUs to enter substance abuse treatment, especially when the workers offer coupons for free treatment (Ashery et al., 1993; Bux, Iguchi, Lidz, Baxgter, & Platt 1993). Outreach workers' success with other types of medical referrals for this population is not documented in the literature.

In 1991 the Centers for Disease Control (CDC) began the AIDS Evaluation of Street Outreach Project (AESOP), a five-year collaborative research study that targeted IDUs in five cities: Atlanta, Chicago, Los Angeles, New York, and Philadelphia. This study was designed to increase understanding of client characteristics, service delivery, and the effects of street outreach programs on the risk behaviors of high-risk populations (CDC, 1993). The scope and efficacy of outreach were measured through cross-sectional interviews before and after site-specific program enhancements were implemented.

In addition to questioning IDUs about their high-risk behaviors, the AESOP interviewers gathered information on the interactions between IDUs and outreach workers, including interaction regarding referrals to medical services. That IDUs reported contact with outreach workers representing many different agencies in the five cities - not just the agencies affiliated with AESOP - presented an opportunity to examine the role of street outreach in providing medical referrals and encouraging this population to act on these referrals. This article addresses the following research questions:

* What level of exposure to street outreach services did IDUs report (what was their frequency of contact, did they have contact with workers delivering the AESOP enhancements, and had they seen skill-building demonstrations for safer sex and drug-using behaviors)?

* What were the most common medical referrals provided during such contacts?

* Did IDUs report acting on these referrals?

* What were the predictors of acting on referrals?
Table 1. AESOP Enhancements Related to Medical Service Referrals

Site Activities

Atlanta On-site STD testing and counseling and HIV C&T
 through mobile van; training of peer educators to
 assist in the referral process; training of outreach
 workers to stage(a) IDUs for readiness to change risk
 behaviors.

Chicago On-site HIV C&T; training of outreach workers in the
 identification of service needs; and case management
 through mobile van.

Los Angeles On-site HIV C&T; training of outreach workers and a
 referral specialist for delivery and documentation of
 referrals for drug treatment and other services;
 training of outreach workers to stage IDUs for
 readiness to change risk behaviors; referral tracking
 system.

New York Training of outreach workers and addition of referral
 specialist for drug treatment referrals.

Philadelphia Referring/escorting clients to drug treatment or HIV
 services; training of outreach workers to stage IDUs
 for readiness to change risk behaviors.

NOTES: AESOP = AIDS Evaluation of Street Outreach Project; STD =
sexually transmitted disease; C&T = counseling and testing; IDUs =
injecting drug users.

a Staging refers to identifying the five stages of progress that
people typically move through when changing behaviors:
precontemplation, contemplation, ready for action, action, or
maintenance (see Fishbein & Rhodes, 1997, for how the
Transtheoretical Stage Model can be applied in HIV prevention).


Findings should benefit clinical and managerial social workers in agencies serving IDUs and their families (for example, social workers in drug treatment and HIV case management programs), as well as practitioners in academic settings.

METHOD

Enhancements Related to Improving Referrals to Medical Services

As part of site-specific enhancements to existing outreach services, researchers designed a number of activities related to improving medical services referrals (Table 1). These components included a mobile van in which services such as case management were delivered, improved training for outreach workers in assessing clients' readiness to change behaviors, a referral specialist who was available to IDUs in one intervention community, and a referral tracking system for verifying that IDUs used services. The tracking system, developed by Los Angeles AESOP researchers as part of their enhancement, consisted of a two-part referral card passed out by the outreach workers and submitted by the IDU on reporting to the service agency. An agency employee stamped both parts, mailing one to AESOP researchers and giving the second to the IDU for return to the outreach worker. Researchers used data from this system to determine which medical referrals IDUs were receiving from outreach workers and which services the IDUs were acting on. The other sites had no formal tracking systems.

AESOP researchers reported that in most circumstances the targeted population initiated the referral process with an outreach worker either by requesting a particular service or by complaining about their physical health. The referral strategy of outreach workers who delivered the AESOP enhancements varied from providing the name and address or phone number of an agency to taking an IDU to a case manager for screening and then taking that individual to a service appointment. Information was not available on how outreach workers not associated with the AESOP enhancements conducted referrals or what resources they had at their disposal, but we assume that their referral processes and resources also varied.

In one referral situation, AESOP outreach workers in Los Angeles observed that a drug user, known in the community to be HIV-seropositive, appeared ill. They transported this homeless woman, along with her shopping cart of belongings, to a drug-free recovery home where she was assessed to be in need of medical attention. The outreach workers then drove her to a hospital where she was admitted and treated for pneumonia. They visited her daily; when she was discharged, they drove her to the recovery home, checked her in, and returned her belongings.

Study Design

A quasi-experimental design with a study and comparison area was used for each of the five sites. Each area was to have adequate numbers of the target group and some continuing level of street outreach. Cross-sectional surveys of the target populations were conducted before and after development and implementation of intervention enhancements in the study areas.

Sample

The AESOP study used a systematic sampling method (see Anderson et al., 1996, for a detailed description) that interviewed on-the-street populations before and three to nine months after introducing enhancements to existing outreach programs in intervention areas. Researchers identified fixed sites (shelters, drop-in centers, meal programs) and on-street congregating areas (for example, drug-buying, or "copping," areas) where IDUs were to be found. A predetermined percentage of interviews was set for both fixed and on-street sources. Respondents were selected within a location using systematic methods, such as selecting every nth potential respondent, counting in a predetermined order. Interviews were scheduled by time of day and day of week so that all relevant times would be represented. To be considered eligible for inclusion in the surveys, participants in all five cities had to be age 18 or older and located within the geographic boundaries of the intervention or comparison areas and had to report injecting illegal drugs within the preceding three years.

Interviewing Process

Interviewers were agency employees, who maintained a separate identity from the outreach workers delivering the enhanced services. They received formal training from CDC in administering the structured questionnaire, with additional training and supervision provided by the researchers on site. Interviewers typically requested visual verification of recent injection or scarring from long-term intravenous injection or relied on the outreach workers' knowledge of informants' behavior. Participants received a payment ranging from $5 to $15 in cash or coupons for fast-food restaurants for their interview time. The interview, which lasted on average from 35 to 40 minutes, included questions on demographics, exposure to outreach, sexual behaviors, and drug-using behaviors. Questions on exposure to outreach included general questions about outreach workers and the following questions about the worker the IDU knew best:

* Who does this outreach worker work for? How many times have you talked with him or her in the past six months? When was the last time you talked with him or her? Where did you talk with him or her?

* Have you talked with him or her about sexual or drug-using behavior? how to correctly use a condom? how to clean needles properly?

Respondents were also asked whether the outreach worker had provided referrals to particular services (for example, drug treatment, treatment for a sexually transmitted disease [STD], AIDS counseling and testing, homeless shelters, health care services, drop-in centers, food lines, prenatal care, and other services) and whether he or she had gone to the service.

Analyses

For these analyses, we focused on 3,237 interviews conducted with IDUs in the intervention and comparison areas of each city. Between January 1994 and October 1995, two waves of interviews were conducted after enhancements to the AESOP outreach programs in the intervention areas. Because the majority of IDUs (72 percent to 93 percent) linked the outreach worker they knew best to a non-AESOP agency, intervention and comparison data were pooled across cities. These outreach workers represented over 33 agencies in the five cities, including the eight agencies delivering the AESOP enhancements.

In analyzing the relationship between receiving and acting on referrals, we relied on the series of items from the surveys that pertained to exposure to outreach. We compared the sites with respect to the percentage of IDUs who indicated receiving referrals in the preceding six months for substance abuse treatment, STD treatment, HIV counseling and testing (C&T), and general medical services for treatment of conditions such as needle-induced abscesses, colds and flu, and chronic health problems. We also compared sites as to the percentage of IDUs who said they had acted on these referrals. Results were analyzed using both bivariate correlation and multiple regression. Chi-square analyses revealed four predictor variables that were significantly related (p [less than or equal to] .05) to IDUs' acting on referrals: age 30 or younger, female, white, and seeing an outreach worker four or more times in the preceding six months.

[TABULAR DATA FOR TABLE 2 OMITTED]

Using logistic regression, acting on referrals was then regressed on the linear combination of these predictor variables. The regression models focused only on respondents who reported receiving a referral. To investigate the relationship between cities and the effect of enhancements, we estimated the odds of successful referral for each of the four service outcomes with and without stratifying by city. For three of the outcomes (all except acting on substance abuse treatment referrals), the comparison between raw and summary odds ratios, adjusted for city, showed that there were still positive associations between the intervention enhancements and referral outcome after stratification. Therefore, we also included city and whether the respondent was interviewed in a geographic area receiving the AESOP enhancements in the models. A separate regression model was run for each of the four medical referrals of interest.

FINDINGS

Exposure to Outreach Services

Most of the IDUs in this sample (N = 3,237) were male (74 percent) and represented ethnic minority populations, with 70 percent being African American and 23 percent Hispanic. The vast majority (93 percent) were age 30 or older. IDUs reported a variety of interaction with outreach workers, from talking with the workers to receiving demonstrations on how to use a condom and how to clean needles to reduce the risk of acquiring or transmitting HIV (Tables 2 and 3). On average, about half the IDUs had talked with an outreach worker within the past six months, and about one-third had talked with an outreach worker in the past month. These workers represented a wide [TABULAR DATA FOR TABLE 3 OMITTED] variety of outreach programs, not just the enhanced AESOP programs. IDUs in both Los Angeles and New York linked street outreach workers to more than nine different agencies operating in their respective communities; Atlanta IDUs identified seven agencies; Philadelphia IDUs named five agencies; Chicago IDUs named four agencies. Within each city the number of agencies operating in the intervention and comparison areas were similar. Identification of outreach workers with an agency delivering the AESOP enhancements ranged from 8 percent to 35 percent across cities, with the highest percentage in Atlanta, where AESOP outreach workers covered both the intervention and comparison communities but delivered the intervention enhancements only in the former. With respect to the outreach worker they knew best, 7 percent to 28 percent of IDUs across cities linked this worker to an enhanced AESOP program. However, 9 percent to 31 percent of respondents across all sites could not identify the organization that employed the outreach worker known best to them.

Receiving and Acting on Medical Referrals

HIV Counseling and Testing (C&T). IDUs reported receiving referrals in the preceding six months to a variety of health-related services from the outreach worker they knew best, including referrals to substance abuse treatment, HIV counseling and testing, STD treatment, and other health needs, including emergency room services. The highest percentage of referrals was reported for C&T - 35 percent to 63 percent across all five cities. Twenty-five percent to 77 percent of those referred said that they had gone for the HIV C&T service [ILLUSTRATION FOR FIGURE 1 OMITTED].

Substance Abuse Treatment. Between 36 percent and 66 percent of IDUs reported being referred for substance abuse treatment, and 14 percent to 55 percent of those referred reported going for treatment [ILLUSTRATION FOR FIGURE 2 OMITTED]. Sixty-seven percent to 77 percent of all IDUs reported having been in treatment previously, and 27 percent to 48 percent had participated in substance abuse treatment within the past six months.

STD Referrals. Twenty-seven percent to 40 percent of IDUs reported receiving referrals for STD treatment. Reports of actually going for STD services ranged from a high of 39 percent in Philadelphia to a low of 4 percent in New York [ILLUSTRATION FOR FIGURE 3 OMITTED].

General Medical Care Referrals. Between 16 percent and 36 percent of IDUs reported receiving other medical care referrals [ILLUSTRATION FOR FIGURE 4 OMITTED]. Reports of going for such services ranged from a high of 57 percent in Philadelphia to a low of 17 percent in New York.

Follow-up Rates from Los Angeles IDUs Receiving AESOP Enhancements. Data from the Los Angeles referral tracking system documented that 52 percent of those referred to four types of medical services acted on those referrals. Forty-five percent of all referrals were to substance abuse treatment, and 40 percent were to HIV C&T. However, only 34 percent of IDUs who were referred for substance abuse treatment went to a treatment program as documented by a referral card, whereas over 95 percent went for HIV C&T. These verified rates are considerably higher than the self-reported rates by all IDUs interviewed in the Los Angeles area, where self-reported access to substance abuse treatment was 14 percent and for HIV C&T was 33 percent.

Results of Logistic Regression Analyses

When the demographic, frequency of contact, city, and enhanced compared with standard variables were entered simultaneously into a regression model, the following predictors of seeking medical services emerged (Table 4). IDUs who indicated seeing their best-known outreach worker four or more times during the preceding six months were more likely than those with less frequent contact to report going for counseling and testing (odds ratio = 1.72, CI = 1.37, 2.16), substance abuse treatment (odds ratio = 1.33, CI = 1.06, 1.67), and general health referrals (odds ratio = 1.51, CI = 1.10, 2.09). White IDUs were twice as likely as members of other ethnic groups to report going for counseling and testing (odds ratio = 1.82, CI = 1.08, 3.05) and substance abuse treatment (odds ratio = 2.01, CI = 1.23, 3.28) and were four times as likely to report going for other health services (odds ratio = 4.40, CI = 1.76, 11.02). Women were more likely than men to report going for HIV C&T (odds ratio = 1.69, CI = 1.32, 2.18) and substance abuse treatment (odds ratio = 1.38, CI = 1.07, 1.76). Using New York as the comparison city, only Philadelphia was significantly associated with IDUs' reporting going for substance abuse treatment services [TABULAR DATA FOR TABLE 4 OMITTED] (odds ratio = 2.59, CI = 1.85, 3.63). IDUs in Atlanta, Chicago, Los Angeles, and Philadelphia were more likely to report going for HIV C&T and STD referrals, and IDUs in Atlanta, Los Angeles, and Philadelphia were more likely to report going for general health services. Being in an enhancement area was a significant predictor of going for STD treatment, with IDUs interviewed in the enhanced areas twice as likely as those in comparison areas to report going for such services (odds ratio = 2.17, CI = 1.51, 3.11).

DISCUSSION

Relationship of Outreach Exposure to Acting on Medical Referrals

Frequent contact with outreach workers was an important factor in acting on referrals for this sample of IDUs. However, only 53 percent of respondents reported talking with any outreach worker over the preceding six months, and only 36 percent of IDUs interviewed had talked with any outreach worker at least once a month. These findings suggest that outreach workers are missing a significant proportion of this population, possibly because, rather than aggressively seeking less available IDUs, outreach workers often position themselves along main walkways where IDUs must seek them. This explanation has been documented previously (Rivera-Beckman, 1991; Wiebel, 1988). IDUs who do not customarily approach outreach workers may have been motivated by interview incentives to interact with interviewers.

Enhancement Areas and Medical Services

Given the array of outreach programs other than AESOP operating in both comparison and enhancement areas and given the small number of IDUs who linked their outreach workers with an AESOP agency, it is not surprising that being interviewed in enhancement areas did not predict acting on a referral. AESOP outreach workers stressed following through with the referrals, but the degree that workers from other agencies encouraged IDUs to use services is unknown. As to why the enhancement areas did predict STD referrals, accessibility to services appeared to be a major factor. In Atlanta - the site that reported the highest exposure to AESOP workers - the enhancement included a mobile health van that offered STD screening. The van traveled throughout the enhancement area. In Los Angeles, a van offering C&T independent of the AESOP project covered the enhanced community only. STD workers accompanied this mobile testing unit and would sometimes go with members of the AESOP outreach staff to locate clients. In Philadelphia, two clinics offering STD testing and treatment were located within walking distance of the intervention area; STD services were not as convenient for the comparison area's clients.

Philadelphia researchers cited a number of other factors to explain the differences in acting on STD referrals between their intervention and control communities.

* The outreach workers delivering the AESOP intervention viewed themselves as community health workers rather than HIV outreach workers. They emphasized STD in their risk assessment discussions with IDUs, who seemed more comfortable at first talking about STD risks rather than HIV risks. Intervention services included a handout with information about a number of specific STDs.

* The Philadelphia outreach workers in the intervention area also emphasized the importance of continuing contact with IDUs; outreach workers sought their previous clients.

* Outreach workers used behavioral change theory to evaluate clients for readiness for change and offered customized intervention messages (see Fishbein & Rhodes, 1997). If workers perceived that a client was really motivated to seek STD evaluation and treatment, they would accompany him or her to the nearest clinic offering STD services.

In spite of accessibility, only a minority of IDUs who received STD referrals indicated acting on these referrals. Without treatment, infected people risk serious long-term sequelae such as infertility and genital cancers. Moreover, given the increasing evidence that both ulcerative STDs such as syphilis and inflammatory STDs such as gonorrhea increase the risk of HIV transmission (Grosskurth et al., 1995; Institute of Medicine, 1997), this is a major public health concern.

Follow-up rates from the Los Angeles card return implemented in the enhancement area were considerably higher than subject-reported rates from the AESOP cross-sectional surveys. In Los Angeles, AESOP outreach workers were trained to establish closer linkages with services. In particular, outreach workers were asked to screen clients carefully for readiness to change drug-using behavior before referring clients to substance abuse treatment services. Only those clients who were seen as "ready for action" were referred. Because these card return rates reflect only referrals by the AESOP outreach workers, these rates suggest the importance of training outreach workers in the referral process.

Influence of City

Our findings show that, independent of being in an enhanced area, city was a significant predictor of IDUs' going for medical services. When Atlanta, Chicago, Los Angeles, and Philadelphia are compared with New York with respect to IDUs' reporting for medical referrals other than substance abuse treatment, the numbers were four to 12 times higher for HIV C&T; three to 15 times higher for STD treatment; and two to six times higher for general health referrals. IDUs in Philadelphia were 2 1/2 times more likely to report for substance abuse treatment than IDUs in New York. Philadelphia researchers attributed these higher numbers to the absence of a central intake process in Philadelphia for getting into substance abuse treatment. As a result, street outreach workers became facilitators and were often sought for such referrals. As noted previously, many outreach programs operated in each geographic area. Extensive ethnographic research in both intervention and control communities in all five cities would have been required to explain observed differences.

Impediments to Tracking of Referrals

Feedback from the sites suggests a number of impediments to tracking referrals. Federal confidentiality laws concerning the records of alcohol and drug abuse patients made it difficult to get treatment information directly from the substance abuse treatment staff. From the client side, IDUs may lose the release of information form provided to them or may fail to return the form to outreach workers from the service agency. Although one site had a memorandum of agreement with a substance abuse treatment agency to provide monthly referral information, the substance abuse treatment staff provided no feedback. Because of sporadic client contact, tracking of IDUs through the referral process was seen by researchers as a difficult and time-consuming task that outreach workers did not see as part of their jobs. Chicago and New York reported that case managers within outreach programs greatly assisted with obtaining agency feedback and built linkages not only with referral agencies but also with families.

Self-Help - A Missing Link

Although the majority of IDUs indicated they had received previous drug treatment, none of the five sites indicated a focus on referrals to aftercare services or self-help groups such as Narcotics Anonymous. An analysis of National AIDS Demonstration Research Project data indicated that self-help groups attracted younger, more recent users before these users enter traditional treatment (French, Rosen, Freeman, & Rodriguez, 1993), and another study found that entry into treatment was related to involvement in self-help groups (Sibthorpe, Fleming, Tesselaar, Gould, & Nichols, 1996). Recent studies of IDUs who attend HIV-positive support groups have shown a significant decrease in drug use related to attendance (Greenberg, Johnson, & Fichtner, 1996; MacGowan et al., 1997). Therefore, it would seem important for outreach referrals to address self-help and aftercare services to the same extent that they address getting clients into formal substance abuse treatment. As noted by Brown and Needle (1994), there is a need for community-based support for clients and their sex partners beyond the time of traditional treatment, or what we term "a graduated exit from treatment." This support involves services to assist the recovering drug user in learning the role of a sober member of society, including referrals for new support systems, such as churches, short-term crisis counseling, and other community resources.

Limitations

In each city there were numerous agencies providing outreach services; therefore, the findings are not representative of the efforts of any single agency's ability to refer IDUs for services. The findings may not be generalizable to all outreach agencies in these locations. Evaluating outreach agency referral systems was not the focus of the AESOP study. As a result, survey items were limited to a checklist of possible referrals and whether the IDU said he or she went for these services. For example, no feedback was obtained on type of substance abuse treatment, length of stay in the treatment, or aftercare. Data were reported by clients in cross-sectional surveys, but follow-up interviews were not conducted, and use of services by participants could not be verified. It was difficult to compare cities, because outreach coverage varied significantly depending on the geographic area. In Chicago, for example, movement of IDUs likely affected contact with outreach staff from the enhanced programs as well as from other programs. Outreach workers believe that construction preparations for the 1996 Democratic National Convention in Chicago resulted in a number of IDUs spending less time in the enhancement area, which limited their exposure to enhanced program services that included a case manager.

Implications for Social Workers

The findings show that outreach workers from a variety of agencies reached a sizeable percentage of IDUs in their communities over a six-month period and provided referrals for medical services, especially for HIV C&T and substance abuse treatment services. Even with extensive enhancements to particular programs, a cadre of outreach workers representing many agencies failed to reach the majority of IDUs at least once a month.

Only a minority of IDUs referred for medical services reported actually going. For example, 30 percent of all IDUs interviewed reported acting on substance abuse treatment referrals. More frequent contact with outreach workers (four or more contacts in this period) was associated with acting on referrals. This finding suggests that outreach workers need multiple interactions with IDUs, during which workers continually reinforce referral messages.

Because participation in substance abuse treatment programs has been associated with reductions in risky behavior for HIV (Caplehorn & Ross, 1995; Longshore, Hsieh, & Anglin, 1994; MacGowan et al., 1997), referral to substance abuse treatment is important. As suggested by Gross and Brown (1993) and supported by AESOP findings, the role of the indigenous outreach worker needs to be broadened to establish links to relevant services and to motivate clients to use such services, as a case manager might do. In particular, when outreach programs create links to STD services for their clients, these programs can be a very effective catalyst for prevention of HIV infection, because a number of different STDs have been shown to increase risk both for acquiring and for transmitting HIV infection (see Boily & Anderson, 1996; Wasserheit, 1992).

CONCLUSION

Improving the effectiveness of street outreach services in linking IDUs with medical services is an important task for clinical and managerial social workers in health care. Both outreach programs and social services agencies could benefit from cross-training that focuses on the following areas:

* strategies for increasing contact with less visible IDUs

* coordination of multiple agency outreach activities with respect to coverage and services

* identifying and overcoming barriers to seeking medical services, especially for clients of color

* techniques for tracking referrals

* reporting of physical and sexual abuse

* advocating for client services such as aftercare, dental services, and prenatal care

* incorporating case management into outreach programs

* the relationship between STDs and HIV transmission.

Closer liaisons with street outreach programs may also be of use to academic social work departments in terms of training opportunities for students and joint applications for funding research in areas such as evaluating the effectiveness of community aftercare programs.

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ABOUT THE AUTHORS

Judith B. Greenberg, PhD, is a health scientist, Robin MacGowan, MPH, is a health scientist, and Mary Neumann, PhD, is a behavioral scientist, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, NE, MS E-44, Atlanta, GA 30333; e-mail: jbg2@cdc.gov. Anna Long, PhD, is chief of staff, Public Health Programs and Services, Los Angeles County Department of Health, Los Angeles. Rose Cheney, PhD, is a senior research associate, Philadelphia Health Management Corporation, Philadelphia. Daniel Fernando, PhD, is adjunct professor, John Jay College of Criminal Justice, New York. Claire Sterk, PhD, is associate director, Department of Behavioral Sciences, Rollins School of Public Health, Emory University, Atlanta. Wayne Wiebel, PhD, is project director, School of Public Health, University of Illinois, Chicago.
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Author:Greenberg, Judith B.; MacGowan, Robin; Neumann, Mary; Long, Anna; Cheney, Rose; Fernando, Daniel; St
Publication:Health and Social Work
Date:Nov 1, 1998
Words:5981
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