Carol S. Weisman

Condom use to prevent incident STDs: the validity of self-reported condom use.

Background Studies of sexual behavior and of interventions designed to reduce human immunodeficiency virus risk usually depend on self-report. Validation of self-reported condom use measures has not been previously reported in an urban population at high risk for sexually transmitted diseases and human immunodeficiency virus. Methods A prospective cohort study was performed in subjects recruited from sexually transmitted disease clinics in Baltimore. At enrollment, a questionnaire was administered that assessed human immunodeficiency virus risk factors and sexually transmitted disease history, and used a retrospective calendar to assess sexual events and condom use over the previous 30 days. Clinical evaluation was performed for sexually transmitted diseases. At follow-up 3 months later, the same procedures were repeated. Incident sexually transmitted diseases at follow-up were defined as new culture or serologically documented diagnoses of gonorrhea, chlamydia, syphilis, or trichomoniasis. Results In the 323 male and 275 female (total = 598) subjects who completed a follow-up visit, 21% reported using condoms for every act of sexual intercourse over the previous 30 days, 21% reported occasionally using condoms, and 59% reported not using condoms. At follow-up, 21% of subjects had new incident gonorrhea, chlamydia, syphilis, or trichomoniasis. Fifteen percent of the men who were “always” condom users had incident sexually transmitted diseases compared with 15.3% of “never users;” 23.5% of women who were “always” users had incident sexually transmitted diseases compared with 26.8% of “never” users. Conclusions In this high-risk population, self-reported condom use is not associated with lower sexually transmitted disease incidence. This finding suggests that self-reported condom use measures, even in a research setting, may be subject to substantial reporting bias.

The Accuracy of Substituted Judgments in Patients with Terminal Diagnoses

When patients face end-of-life decisions and are unable to speak for themselves, loved ones are often asked to make substituted judgments. Ethicists have argued that this is an important way of respecting patient autonomy [1, 2], but preliminary studies indicate that substituted judgments may not be very accurate [3-11]. This concern has led some observers to question the usefulness of asking for substituted judgments [8, 12]. If the concept of substituted judgment is to remain clinically useful, health care professionals need a better sense of the circumstances under which substituted judgments made by surrogates are accurate or inaccurate. Such data may alert clinicians to instances in which patients are at risk for having their wishes misrepresented and may aid in the design of education campaigns to improve the accuracy of substituted judgments. Little is known about the factors associated with accurate substituted judgments, especially among patients with terminal diagnoses [8, 11]. In a pilot study of 50 general medical patients [13], we found that accuracy was positively associated with discussions between patients and surrogates and negatively associated with religiosity. Building on this experience, we studied 250 terminally ill patients and their legal surrogates and a comparison group of 50 general medical patients and their surrogates. Our objectives were to 1) assess the accuracy of the substituted judgments made by the surrogates; 2) ascertain the beliefs, practices, and clinical and sociodemographic factors associated with accuracy; 3) assess the preferences of patients for life-sustaining treatments; and 4) compare differences in accuracy across diagnoses. Methods Patients Between November 1993 and February 1996, patients were recruited from the outpatient practices of Johns Hopkins Hospital and the Hopkins Bayview Medical Center, Baltimore, Maryland, and Georgetown University Medical Center, Washington, D.C. Eligible patients were older than 17 years of age, spoke English, and had one of the following conditions known to be associated with a less than 50% chance of surviving for 2 years: New York Heart Association class III or IV congestive heart failure with no possibility of transplantation [14], advanced HIV infection according to the Centers for Disease Control and Prevention case definition for AIDS (before the use of protease inhibitors) [15], amyotrophic lateral sclerosis with respiratory compromise [16], unresectable non-small-cell lung cancer [17], or oxygen-dependent chronic obstructive pulmonary disease with dyspnea at rest [18, 19]. Treating physicians were asked to exclude patients whom they thought they were likely to live longer than 2 years and patients who were cognitively incapable of participating. The comparison group comprised general medical patients who were older than 64 years of age, spoke English, and were expected to live longer than 2 years. To have a power of 0.80 to detect a 15% difference between patient preferences and surrogate predictions at = 0.05, we needed 263 patient-surrogate pairs. Rounding up to 300 gave a power of 0.75 to detect a 25% difference in agreement between diagnostic groupings at = 0.05. Surrogates were chosen according to Marylands legal hierarchy of surrogates for incapacitated patients: durable power of attorney, guardian, spouse, adult child, parent, sibling, other relative, or friend [20]. For uniformity, surrogates of patients recruited at Georgetown University Medical Center were also chosen according to the Maryland hierarchy. Attending physicians were contacted 2 weeks before scheduled patient visits. Patients were initially informed of the general nature of the study and asked to supply the phone number of the surrogate who was highest in Marylands legal hierarchy. At the time of the appointment, details of the study were described and informed consent was obtained. Surrogates were interviewed within 48 hours before or after the patient interview. Patients and surrogates were asked not to speak with each other about the interviews until both interviews were completed. Informed consent was obtained from all participants. The study was approved by the institutional review boards of the Johns Hopkins Medical Institutions and Georgetown University Medical Center. Interview Schedule Structured interviews consisted of closed-ended questions about sociodemographic factors, previous discussions about end-of-life decisions, advance directives, and past experiences. Patients were asked about their treatment preferences, and surrogates were asked to predict patient preferences. Sociodemographic information included age, sex, ethnic group, exposure category for HIV infection, level of education, socioeconomic factors, insurance status, and religious beliefs and practices. We elicited preferences for various medical interventions in the setting of three hypothetical clinical scenarios that would render patients unable to make decisions for themselves: permanent coma, coma with a small chance of recovery (the small chance scenario), and severe dementia (Table 1). For each scenario, the patient was asked to report his or her preferences for intensive care, intubation, cardiopulmonary resuscitation, feeding tube placement, nasotracheal suction, surgery, hemodialysis, esophagogastroduodenoscopy, phlebotomy, and chest roentgenography. All scenarios and interventions were described briefly and simply to ensure understanding. For example, the feeding tube question was worded, Would you want to be fed by a feeding tube (that is, a tube put through your nose or through the skin over your stomach)? Table 1. Clinical Scenarios Requests for a limited trial of an intervention were interpreted as yes responses. Patients and surrogates were urged to give their best judgment. Unsure responses were recoded as yes responses because they would be clinically interpreted that way. The interview schedules had been previously developed and tested for reliability [13] and were based on the Medical Directive of Emanuel and Emanuel [21]. Slight modifications were made for our protocol; the revised instruments showed high internal consistency, with Kuder-Richardson statistics of 0.97 for the permanent coma scenario, 0.94 for the small chance scenario, and 0.93 for the severe dementia scenario. The complete set of instruments is available from the authors on request. Surrogate Accuracy in Matching Patient Preferences Scale Scores We constructed a Surrogate Accuracy in Matching Patient Preferences Scale (SAMPPS) for each of the three scenarios (SAMPPS-1 for permanent coma, SAMPPS-2 for small chance, and SAMPPS-3 for severe dementia). This scale assigns a score of 1 when the surrogates prediction correctly matches the patients preference for each scenario-treatment pair. Mismatches are assigned a score of 0. The sum of the correct answers constitutes the SAMPPS score. For each of the three scenarios, a perfect score is 10 and a complete mismatch has a score of 0. Statistical Analysis Categorical variables were analyzed by using the chi-square test or the Fisher exact test. Two-tailed t-tests were used for paired continuous variables. Analysis of variance was used to compare continuous variables across multiple groups. Differences between surrogate and patient demographic characteristics were examined by using the McNemar test for paired comparisons. The McNemar test was also used to assess any pattern in mismatches between patient and surrogate preferences. Differences in patient preferences for treatment according to modality or scenario were assessed by using the Cochran Q test. Although scores have often been reported in similar studies, we do not report them because of concern about the appropriateness of as a test of surrogate accuracy [11, 22], and the paradox of [23]. We presented elsewhere an alternative to chi for measuring surrogate accuracy [24]. Factors Associated with the Accuracy of Substituted Judgments A skewed distribution was found for SAMPPS scores. The Friedman two-way analysis of variance was used to compare SAMPPS scores across scenarios, and the Kruskal-Wallis one-way analysis of variance was used to compare SAMPPS-1 scores across diagnoses. A binary logit model [25] was constructed using the 10 binary items (correct/incorrect) per patient-surrogate pair of the SAMPPS-1 score. Independent variables were screened for association with SAMPPS-1 score by using the Spearman rank correlation and Kruskal-Wallis tests, as appropriate. Variables that did not contribute significantly to the multivariate model were eliminated in a stepwise manner. When diagnostic categories were stratified by age ( 65 years or <65 years), the log odds differed significantly by age group for patients with amyotrophic lateral sclerosis, but no such interaction was found between education and insurance. Model diagnostics to identify influential observations were examined [26], revealing 9 outliers that were subsequently removed from the final model. Thus, the final model reports on only 291 patient-surrogate pairs. The model was validated by using the independent variables found to be significant in the SAMPPS-1 model to predict the SAMPPS-2 and SAMPPS-3 scores. Results Participants Interviews of both patient and surrogate were completed for 75% of pairs that met study inclusion criteria. Of interviews that were not completed, 51% were not completed because of patient refusal; 25% were not completed because of patient refusal to allow surrogate contact; 15% were not completed because of surrogate refusal; and 9% were not completed for other reasons, chiefly our inability to arrange for a surrogate interview within 48 hours of the patient interview. Compared with participants, nonparticipants were older (68 and 60 years of age; P < 0.001), more likely to be female (65% and 39%; P < 0.001), more likely to receive Medicare (24% and 10%; P < 0.001), and more likely to be in the chr

Physician gender effects on preventive screening and counseling: an analysis of male and female patients' health care experiences.

Background. Studies have documented that patients of female physicians receive higher levels of preventive services. However, most studies include patients of only one gender, examine mainly gender-specific screening services, and do not examine patient education and counseling. Objectives. This study tests both physician- and patient-gender effects on screening and counseling services received in the past year and considers effects of gender-matched patient-physician pairs. Research Design. Multivariate analyses are conducted to assess direct and interactive (physician × patient) gender effects and to control for important covariates. Subjects. Data are from the 1998 Commonwealth Fund Survey of Women’s Health, a nationally representative sample of U.S. adults. The analytic sample includes 1,661 men and 1,288 women ages 18 and over. Measures. Dependent variables are measures of patient-reported screening and counseling services received, including gender-specific and gender-nonspecific services and counseling on general health habits and sensitive topics. Results. Female physician gender is associated with a greater likelihood of receiving preventive counseling for both male and female patients. For female patients, there is an increased likelihood of receiving more gender-specific screening (OR = 1.36, P <0.05) and counseling (OR = 1.40, P <0.05). These analyses provide no evidence that gender-matched physician-patient pairs provide an additional preventive care benefit beyond the main effect of female physician gender. Conclusions. Female physician gender influences the provision of both screening and counseling services. These influences may reflect physicians’ practice and communication styles as well as patients’ preferences and expectations.

Consistency of Condom Use for Disease Prevention Among Adolescent Users of Oral Contraceptives

A six-month prospective study examined consistency of condom use for disease prevention among 308 adolescent women who had received a prescription for oral contraceptives at a family planning clinic. Only 16 percent used condoms consistently over a six-month period, yet 30 percent were considered at high risk for sexually transmitted diseases (STDs) because of multiple, sequential or concurrent relationships with male partners. The type of relationship in which the adolescents were involved did not predict consistency of condom use. Consistent condom use was associated with having asked a partner to use a condom, perceiving partner support for condom use, having less frequent sexual intercourse and using oral contraceptives inconsistently. The findings suggest that family planning providers need to more strongly emphasize to adolescents the importance of consistent condom use to protect against STD infection.

Partner-specific condom use among adolescent women clients of a family planning clinic.

Because inconsistent condom use could put adolescent women at an increased risk for sexually transmitted diseases, it is important to understand when and with whom they use condoms. This study examined partner-specific condom use over time among adolescent women. The data were from a clinic-based, prospective study of 308 adolescent women who had at least one sex partner during a 6-month follow-up. Their condom use was examined with three types of partners: exclusive, nonexclusive primary, and nonexclusive secondary. Predictors of consistent condom use (using condoms 100% of the time with a specific partner) were explored in a multiple logistic regression analysis. Consistent condom use was more likely to occur in shorter relationships (less than 3 months) and with partners who preferred condoms for contraception. It was no more likely to occur with nonexclusive partners than with exclusive partners, and it was somewhat less likely to occur among consistent oral contraceptive users. These findings emphasize the importance of educating adolescent women to introduce and maintain condom use with all partners.

AIDS knowledge, perceived risk and prevention among adolescent clients of a family planning clinic

In a survey that measured AIDS knowledge, perceived risk and prevention among 404 sexually active adolescent women who were family planning clinic patients in Baltimore, knowledge about AIDS was high, with the average respondent answering seven out of nine questions correctly. Slightly more than half of the teenagers reported some degree of perceived risk that they could get AIDS. However, perceived AIDS risk was not predictive of condom use at last intercourse. The strongest predictor of condom use was having asked a partner to use one, suggesting that adolescent women may exert a greater influence on condom use than has been previously assumed. The analyses result in recommendations that personalized AIDS prevention programs be integrated into family planning programs, that adolescent clients be advised to use condoms with spermicides, and that they be assisted in acquiring the social skills needed to negotiate condom use with partners.

Are two doctors better than one? Women's physician use and appropriate care.

This study examines nonelderly womens concurrent use of two types of physicians (generalists and obstetrician-gynecologists) for regular health care and associations with receipt of preventive care, including a range of recommended screening, counseling, and heart disease prevention services. Data are from the 1999 Womens Health Care Experiences Survey conducted in Baltimore, Maryland, using random digit dialing (N = 509 women ages 18 to 64). Key findings are: 58% of women report using two physicians (a generalist and an ob/gyn) for regular care; seeing both a generalist and an ob/gyn, compared with seeing a generalist alone, is consistently associated with receiving more clinical preventive services, including screening, counseling, and preventive services related to heart disease. Because seeing an ob/gyn in addition to a generalist physician is associated with receiving recommended preventive services (even for heart disease), the findings suggest that non-elderly women who rely on a generalist alone may receive substandard preventive care. The implications for womens access to ob/gyns and for appropriate design of womens primary care are discussed.

Postpartum Anxiety and Maternal-Infant Health Outcomes

OBJECTIVE: Postpartum anxiety screening does not typically occur, despite changes in life roles and responsibility after childbirth. We sought to determine the prevalence of postpartum anxiety during the maternity hospitalization and its associations with maternal and child outcomes. We further aimed to compare correlates of anxiety with correlates of depression. METHODS: For a randomized controlled trial of mothers with “well” newborns ≥34 weeks’ gestation comparing 2 post–hospital discharge care models, mothers completed baseline in-person interviews during the postpartum stay and telephone surveys at 2 weeks, 2 months, and 6 months to assess health care use, breastfeeding duration, anxiety, and depression. All participants intended to breastfeed. State anxiety scores ≥40 on the State Trait Anxiety Inventory (STAI) and depression scores ≥12 on the Edinburgh Postnatal Depression Survey (EPDS) were considered positive. RESULTS: A total of 192 (17%) of 1123 participating mothers had a positive baseline STAI; 62 (6%) had a positive EPDS. Primiparity was associated with a positive STAI (20% vs 15%, P = .02), but not a positive EPDS (4% vs 7%, P = .05). Positive STAI scores were associated with cesarean delivery (22% vs 15%, P = .001), reduced duration of breastfeeding (P = .003), and increased maternal, but not infant total unplanned health care utilization within 2 weeks of delivery (P = .001). Positive STAI scores occurred more frequently than positive EPDS scores at each assessment through 6 months postpartum. CONCLUSIONS: Postpartum state anxiety is a common, acute phenomenon during the maternity hospitalization that is associated with increased maternal health care utilization after discharge and reduced breastfeeding duration. State anxiety screening during the postpartum stay could improve these outcomes.

Dysmenorrhea and use of oral contraceptives in adolescent women attending a family planning clinic

OBJECTIVES This study examined the prevalance of dysmenorrhea in female adolescents and the effect of experiencing a reduction in dysmenorrhea on oral contraceptive use. STUDY DESIGN This was a prospective panel study in which 308 adolescent women at an inner-city family planning clinic were interviewed about their experiences with dysmenorrhea and their oral contraceptive use at three points in time over a 6-month period. A chi 2 test and multiple logistic regression analysis were done. RESULTS The overall prevalence of dysmenorrhea in this population was 79.6%; 18.2% reported severe dysmenorrhea. Those who had severe dysmenorrhea and also experienced the reduction of dysmenorrhea as a result of oral contraceptives were eight times more likely to be consistent oral contraceptive users (p less than or equal to 0.02). CONCLUSIONS It is important to screen female adolescents for dysmenorrhea, provide them with information about the beneficial side effects of oral contraceptives, and follow up these young women to make sure they are experiencing the alleviation of their symptoms.

Determinants of Hospital Staff Nurse Turnover

Organizational and nonorganizational determinants of staff nurse turnover are investigated in a panel study of 1,259 nurses employed in two university-affiliated hospitals. Findings are consistent with a causal chain in which perceived autonomy, job satisfaction, intent to leave the hospital and turnover are a sequence of outcomes reflecting the successive stages of a nurses decision to resign. Both personal characteristics and job-related attributes are predictive at various stages of the process, although family status variables have no significant effects. Implications for hospital management of turnover are discussed.