Authored by Meya YB Mongkuo*
Abstract
Aim: Since the early 1980s, excessive consumption among minority young adults (age 18-24 years old) became a severe public health concern in preventing the prevalence of HIV infection. In the United States, minority young adult population have a higher excessive alcohol consumption rate of HIV infection disproportionately infected with the disease than any other racial group. The continued spread of HIV among this vulnerable population has led to a need to identify risk and protective factors and evidence-based prevention strategies to reduce the transmission of the disease. A popular approach is the comprehensive, integrated HIV prevention program (CIHPP), a program based on the ecological epistemology framework. This framework views risk factors as a multilevel concentric system, including the individual, family, community, and societal levels. The theory asserts that any meaningful prevention strategy should examine the effect of these different levels on the population of interest. This study aims at testing the effectiveness of the CIHPP in raising awareness and excessive alcohol consumption risk of minority young adults.
Methods: Data on excessive alcohol risk awareness and alcohol consumption was collected from a survey of a random sample of minority young adults who participated in 24 months of CIHPP. Change in their excessive alcohol risk awareness and use was recorded during the 24 months of their participation in CIHPP. The impact of the CIHPP on excessive alcohol risk awareness and alcohol consumption were evaluated using the latent growth curve model within the framework of the structural equation modeling procedure.
Results: The findings reveal that the CHIPP was effective in raising the excessive alcohol consumption risk awareness and reducing alcohol consumption of the participants. There was a significant inter-individual difference in the original score of excessive alcohol risk awareness between the participants and progressed through 24 months of CIHPP intervention. Regression analysis revealed that excessive alcohol consumption risk awareness of female participants was higher than their male counterparts. There were significant inter-individual differences or heterogeneity in alcohol consumption in the original score of excessive alcohol consumption between the participants. Regression analysis revealed that the male participants consumed more alcohol than their female counterparts.
Conclusion and Discussion: The CIHPP was effective in increasing the awareness of excessive alcohol consumption risk and reducing excessive alcohol consumption among minority young adults. The alcohol awareness of minority young female adults was higher than their male counterparts during the 24 months implementation of the CIHPP. These findings confirmed our research hypotheses and consistent with the results of previous research on evidence-based interventions.
Keywords: Alcohol consumption risk awareness; Excessive alcohol consumption risk; Latent growth curve modeling; Structural equation modeling; Comprehensive HIV prevention program
Introduction
It has been almost four decades when HIV infection became a severe public health problem. Since then, infectious disease experts worldwide have been working without finding a vaccine to immune people from the disease. So the focus has shifted from developing a vaccine to identifying the most effective evidence-based prevention strategies to slow the spread of the disease. In 2017 an estimated 5.1 million or 14.8% of young adults aged 18 to 25 were diagnosed with substance use disorder [1,2]. Other researchers have focused on identifying evidence-based risk and protective factors and prevention strategies to slow the disease [3-8]. Research has found excessive alcohol consumption destabilize the normal functioning of virtually all vital organs that regulate behavior, including the nervous system, the immune system, the digestive system, the endocrine system, and the circulatory system [3,9]. These hormones control metabolism and energy levels, electrolyte balance, growth and development, reproduction, responses to and appropriate coping with changes in the internal and external environments, such as changes in temperature and the electrolyte composition of body fluids, and response to stress, anxiety, and injury [3,5-8,10].
Both acute and chronic alcohol consumption induces hormonal disturbance of the endocrine system that disrupts the body’s ability to maintain homeostasis leading to various disorders, including cardiovascular diseases, reproductive deficits, immune dysfunction, certain cancers, bone disease, and psychological and behavioral disorders. Research has also found that indulgence in excessive alcohol consumption does not only harm the hypothalamicpituitary- adrenal (HPA) axis, but practically all the hormonal systems of the body, including the hypothalamic-pituitary-gonadal (HPG) axis Sakar DK, Gibbs DM [5], the hypothalamic-pituitarythyroid (HPT) axis [11], hypothalamic-pituitary-growth hormone/ insulin-like growth factor-1 (GH/IGF-1) axis [13-15], and the hypothalamic-posterior pituitary (HPP) axis [3,4,17-19].
A recent review of studies on youth and adolescents also suggests that hypothalamic-pituitary-adrenal (HPA) axis dysfunction and exposure to stress are critical components that interact to convey risk for developing attention deficit disorder (AUD) [20]. For example, several randomized clinical trials (RCT) have found that excessive alcohol consumption harms the normal functioning of the nervous and endocrine systems, both of which are responsible for proper communication between various organs and cells of the body to maintain a stable internal environment or homeostasis [21- 22]. Interference of the normal functions of these communication systems sets in motion a series of adverse physiological activities, including disruption of the hormonal control of metabolism and energy levels, electrolyte balance, growth and development, and reproduction of the body. These disruptions, in turn, inhibits the body’s ability to respond to effectively and appropriately adapt to changes in body temperature or the electrolyte composition of the body’s fluids, response to stress and injury, and psychological and behavioral disorders [1, 22-24]. As for the nervous system, excessive consumption of alcohol disrupts the vital hormonal flow of the hypothalamic-pituitary-adrenal HPP axis that is responsible for cognitive brain functioning. The HPP axis includes two neuropeptides called arginine vasopressin (AVP) and oxytocin.
Other research has focused on the progressive alterations in the HPA axis function crucial for understanding the underlying brain mechanisms of substance use, including excessive alcohol consumption disorders. These studies found that in contrast to mood and affective disorders, alcohol dependence has a biphasic effect on HPA axis dynamics as a person traverses through the various phases of heavy hazardous drinking, including dependent alcohol, withdrawal, abstinence, and relapse. Generally speaking, these developmental stages seem to be mirrored by a shift between hyper- and hypo-responsiveness of the HPA axis to stressful events [25]. For example, hyper-responsiveness has been identified in people with a family history of alcoholism [8,10], a population that is at increased risk for alcohol dependence (Windle 1997). Thisfinding raises the question of whether heightened stress responsivity is clinically meaningful to the development of alcoholism. This view is supported by studies showing that cortisol responsivity correlates with the activity of the regulatory function of the nervous system called the mesolimbic dopaminergic pathway, which is a central neural reward pathway [8,26]. The transition to alcohol dependence leads to compensatory allostatic mechanisms result in injury to HPA axis function and elevation of stress peptide levels (e.g., corticotropin-releasing factor (CRF) in brain regions outside the hypothalamus. Allostasis refers to the process through which various biological processes attempt to restore homeostasis when an organism is threatened by multiple types of stress in the internal or external environment [3,27]. Allostatic responses can involve alterations in the HPA axis function, the nervous system, various signaling molecules in the body, or other systems. Allostatic changes in HPA axis function have been posited to, among other things, injure brain reward pathways, contribute to depressed mood (i.e., dysphoria) and craving, and further contribute to the maintenance of problem drinking behavior.
A close examination of the physiology of the hypothalamicpituitary- adrenal (HPA) axis reveals that the body responds to stress with automatic, allostatic processes aimed at returning critical systems to a set point within a narrow range of operation that ensures survival [3,4]. These automatic processes consist of multiple behavioral and physiological components. Perhaps the best-studied element in the stress response in humans and mammals is the activation of the HPA axis. This line of inquiry has found that the neurons in the paraventricular nucleus (PVN) of the hypothalamus release two neurohormones-CRF and arginine vasopressin (AVP)-into the blood vessels connecting the hypothalamus and the pituitary gland (i.e., hypophysial portal blood). Both hormones stimulate the anterior pituitary gland to produce and secrete adrenocorticotropic hormone (ACTH) into the general circulation. The ACTH, in turn, induces glucocorticoid synthesis and release from the adrenal glands located atop the kidneys.
The main glucocorticoid in humans is cortisol, which frequently is used as model systems to investigate the relationship between stress and alcohol use, which is corticosterone. Hypothalamic activation of the HPA axis modulated a variety of brain signaling (i.e., neurotransmitter) systems. Some of these systems have inhibitory effects (e.g., g-aminobutyric acid [GABA] and opioids), whereas others have excitatory effects (e.g., norepinephrine and serotonin) on the PVN. These effects suggest that the central nervous system (CNS) and the hormone (i.e., endocrine) system are tightly interconnected to coordinate glucocorticoid activity [28]. The HPA system carefully modulates through negative-feedback loops designed to maintain predetermined hormone levels (i.e., setpoints) and homeostasis. To this end, Hermann [28] asserts that secretion of CRF, AVP, and ACTH in part controlled by sensitive negative feedback exerted by cortisol at the level of the anterior pituitary gland, PVN, and hippocampus.
Iovino [18] suggest that there are two types of receptors for cortisol-mineralocorticoid (type-I) and glucocorticoid (type- II) receptors-both of which participate in the negative feedback mechanisms. Cortisol binds more strongly (i.e., has higher binding affinity) for the mineralocorticoid receptors (MRS)1 than the glucocorticoid receptors (GRs). Because of this difference in a critical relationship, the MRS help maintain the relatively low cortisol levels circulating in the blood during the regular daily (i.e., circadian) rhythm. Only when the cortisol concentration is high (e.g., during a stressful situation) does it bind to the GRs with lower affinity; the resulting activation of the GRs terminates the stress response. This delicate negative feedback control mechanism maintains the secretion of ACTH and cortisol within a relatively narrow bandwidth [29]. This process is a critical homeostatic mechanism because it regulates too much or too little exposure AVP secreted in response to osmotic stimuli. Also, it restricts the concentration of dissolved molecules (i.e., osmolality) in the blood fluid by retaining water in the body and constricting blood vessels [18,29]. Some AVP is released directly in the brain, and research suggests that it play an essential role in social behavior, sexual motivation and pair bonding, as well as maternal response to stress (Dorin et al. 2003; Ehrenreich et al. 2010).
Excessive alcohol consumption lowers the level of AVP to the brain leading to impaired cognitive performance (Laczi 1987). Like AVP, oxytocin is produced by both magnocellular and parvocellular neurons of the hypothalamus and functions both as a peripheral hormone and a signaling molecule in the central nervous system Buijs [30] to regulate adaption of the body to respond effectively to internal physiological and environmental changes or disruptions. Research on people with a history of excessive alcohol consumption shows that hyperresponsiveness of the stress response is mediated by the HPPA axis [8], leading to mental health problems. Research on animals found acute ethanol administration to rats increased plasma ACTH and corticosterone levels by enhancing CRF release from the hypothalamus [31-32]. Chronic alcohol consumption is associated with anxiety-producing (i.e., anxiogenic) Behavior [33]. Collectively, these studies show that excessive or chronic alcohol consumption attenuates basal ACTH and corticosterone levels and increases stressful and anxiogenic behaviors. Other studies have found an association between excessive alcohol consumption and depression among young adults [34-36].
Rate of excessive alcohol consumption in Cumberland, North Carolina
The Center for Disease Control and Prevention (CDC) reports that Cumberland County’s rate of people drinking five or more drinks of alcohol in one seating of 11.2% is higher than North Carolina State’s rate of 10.5%. Disease prevalence data and study findings suggest that our target populations have a more severe than expected alcohol abuse problem that makes them vulnerable to alcohol-related HIV infection. The CDC also estimates that Cumberland County’s rate of people drinking five or more drinks of alcohol in one seating of 11.2% is higher than North Carolina State’s rate of 10.5% [2]. The North Carolina Department of Health and Human Service (NCHHS) reports that Cumberland County continues to battle against sexually transmitted diseases. North Carolina Department of Health and Human Services reports that in 2013, there 1,339 persons living with HIV infection (PLWHI) in Cumberland County. Of this total, 866 had HIV, and 473 had AIDS. There were 158 PLWHI young adults ages 15-24 years old, representing 0.6% with a corresponding HIV infection rate of 27.7 per 100,000 population in Region 5, which includes Cumberland County. This HIV infection rate is higher than North Carolina’s rate of 25.7 per 100,000 people. Desegregating the PLWHI.rate by regionshows that the rate in Region 5, which includes Cumberland County by race/ethnicity,reveals that except for Hispanics and Asian/Pacific Islanders, the rate of PLWHI for Region 5 was higher than that of North Carolina, with the PHLI.Rate and percent of Americans of 4.9% and 189.6 per 100,000 population areseven times higher than North Carolina’s 0.7% and 175.2 per 100,000 people; African Americans were 69.4% and 710.4 per 100,000 people compared to North Carolina’s 65.4% and 857.8 per 100,000 people. This prevalence data suggest that higher than expected level of HIV infection among our target populations, and hence a need for evidence-based intervention.
Rate of HIV infection in cumberland county, north carolina
North Carolina Department of Health and Human Services report that in 2013, Cumberland County had 97 newly diagnosed HIV infections, which rank 3rd among all North Carolina Counties in newly diagnosed HIV infection rate with 26.0% HIV infections per 100,000 population (97 cases) compared to NC. rate of 15% per 100,000 people. From 1983 to 2013, Cumberland County had a cumulative number of HIV cases of 2,087, which ranks 6th out 100 Counties in North Carolina. During the same period, the County had 910 increasing cases of AIDS, which ranks 6th among the 100 counties in North Carolina. North Carolina State Center for Health Statistics (NCSCHS) reported that during the period 2007- 2011, Cumberland County’s HIV rate of infection of 27.3/100,000 population was 1.54 times higher than the State of North Carolina’s HIV infection rate of 17.7 per 100,000 people. Also, NCSCHS reported that during 2007-2011, Cumberland County’s total AIDS rate of 3.4p/100,000 population was 1.7 times higher than North Carolina State’s overall AIDS rate of 2.0 p/100,000 population and 13% higher than all its peer counties, except for one (Mecklenburg County) in the State of North Carolina.
Theoretical Framework
Theoretical approaches to prevention have three primary assumptions. First, they view prevention as a proactive process by which conditions that promote the well-being of an individual. Prevention activities empower individuals and communities to meet the challenges of life events and transitions by creating conditions and reinforcing individual and collective behaviors that lead to healthy communities and lifestyles. Second, prevention requires multiple processes on multiple levels to protect, enhance, and restore the health and well‐being of high sexual risk populations. Such as minority young adults in Cumberland County. Third, prevention involves an understanding of risk and protective factors that vary among individuals, age groups, racial and ethnic groups, communities, and geographic areas.
Theories, models, and data that allow for the explanation and understanding of sexual risk and protective factors at several levels of social aggregation-community, school, peers, family, and the individual’s characteristics-provide a rational approach to designing appropriate prevention strategies and programs. Risk factors exist in clusters rather than in isolation. Research has shown that these multiple risk factors have a synergistic effect (i.e., the interactions between these risk factors have a more significant impact than any single risk factor) alone. For example, some of the behaviors that put people at heightened risk of contracting and spreading HIV are excessive alcohol consumption, illicit substance, and tobacco use, and having sex with multiple sex partners.
The Comprehensive HIVPrevention Program (CIHPP)
CIHPP is essentially a derivative of Bronfenbrenner’s [37] ecological epistemology framework, which asserts that health risk behaviors such as excessive alcohol consumption, involves complex interactions between social and biological factors [38] March &Susser, 2006; Dalhberg& Krug, 2002; [39] Schiberner et al., 2001. This approach to health risk behavior prevention is considered the most effective evidence-informed strategy to prevent the spread of HIV and other infectious diseases among at-risk populations. This framework emanates from Jessor’s [40] problem behavior theory (PBT), which proposes interrelated concentric domains of risk factors beginning with the individual level, the neighborhood or community level, and societal level [37,39]. Specifically, the states that young adult health risk factors consist of a personality system, social environment, and behavior. The approach extends to the domain of psychosocial theory that views health risk behaviors as co-occurring [40-41] among young adults. Hence, assessing the effectiveness of prevention programs should include examining the association between externalizing problems (such as alcohol consumption) and internalizing problems (such as depression, anxiety, cognitive impairment, and disruptive behavior). Therefore, as suggested by [37], effective prevention strategies should identify and address the prevention of sexually transmitted infections among high-risk individuals and communities at all four levels (i.e., individual, interpersonal, organization, and societal).
The individual level is considered the microsystem where individuals work within their family and home environment, school and peers, work-peer networks, peer support, family support, parental mentoring, and parental involvement in health risk behaviors networks. [37,40-42]. This individual-level characteristic is nested within the broader community, consisting of community norms, attitudes regarding health risk behavior, cultural standards, gender norms, spiritual and religious norms, and ideological and political norms. The prevalence of individual-level health risk behaviors may include having multiple sex partners, having sex without condoms, having concurrence partnerships, sharing infected needles, and readily available alcohol, illicit substance, and tobacco. The prevalence of interpersonal risk behavior is social and sexual network structure (i.e., network size, density, mixing, and turnover) and compositional factors (i.e., characteristics of network members) that influence vulnerable to HIV infection and transmission such as minority young adults HIV transmission [43].
Community-level risk factors include the density of alcohol, tobacco, illicit substance and tobacco outlets, and community social and economic disadvantages, crime, and homelessness [44- 47]. Societal level sexual risk factors consist of public policies that shape the environment of the community, such as policies that promote high density of alcohol and other risky sexual behavior products outlets in poor and minority neighborhoods, leading to segmentation of drinkers in hot spots for HIV risk behaviors and HIV transmission [46]. Also, societal health risks may include institutional racism, stigma, segregation, formal and informal public policies, and religious and cultural norm [44,47].
The macro-policy level may also include the biological and physiological status of essential systems of the body that regulate behavior, including the nervous system, endocrine system, the digestive system, immune system, and renal system. The macropolicy level consists of advertisements and marketing policies related to health risk behaviors [37,39]. Hence, effective prevention strategies and procedures should include considering all these multiple interrelated spheres of influence on behavior to achieve desired health outcomes.
The ecological epidemiology framework of the comprehensive HIV prevention program germane to our study implies identifying the prevalence of HIV infection and transmission rates in the target population by conducting needs assessments of measurable constructs at each level or domain of influence, at cross-level connections at both the micro and macro levels, as well as by examining the macrosocial and microsocial or protective factors (risk regulators) that can either constrain or promote the occurrence of individual-level behavior associated with the risk of HIV infection [48]. The needs assessments, in turn, provide objective data for developing a strategic HIV prevention plan for the target population and community. So far, no research that we know of have has validated the psychometric properties of the expected outcome of CHIPP, as well as an evaluation of the desired results of this prevention intervention strategy, including an increase in excessive alcohol consumption risk awareness, decrease in excessive alcohol consumption. So far, there has been no study that we know of has determined the change in behavior in the behavior of participants over time using the latent growth curve model within the framework of structural equation modeling.
Purpose of the Study
The purpose of this study is to begin a line of inquiry to fill this gap in research by examining the effectiveness of the Comprehensive Integrated HIV Prevention Program in raising awareness and decreased the involvement of risky sexual behaviors among minority young adults. We expect that the study to provide public policymakers, stakeholders, and practitioners with reliable and valid policy-relevant information relied upon in designing efficient and effective public policies to reduce the spread of HIV infection among this vulnerable population.
Research question
This study sought to provide an empirically-ground answer to the following two research questions:
• What is the effectiveness of the comprehensive, integrated HIV prevention program in raising excessive alcohol consumption risk awareness of minority young adults?
• What is the excessiveness of the comprehensive, integrated HIV prevention program in reducing excessive alcohol consumption of minority young adults?
• Research Hypothesis
• The Comprehensive Integrated HIV Prevention Program (CIHPP) effectively increases excessive alcohol consumption risk awareness of minority young adults.
• The (CIHPP) is effective in reduces excessive alcohol consumption among minority young adults.
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