Christine M. Forke

The Use of Levonorgestrel Implants (Norplant) for Contraception in Adolescent Mothers

Background Although levonorgestrel implants (Norplant) would appear to be a good contraceptive option for adolescent mothers, there is little information about the use of Norplant in this population. Methods We studied 100 postpartum adolescents who chose a contraceptive method at an urban teaching hospital between September 1991 and July 1992. Structured interviews were conducted and medical records were reviewed soon after delivery and at a mean (±SD) of 15.5 ±2.9 months post partum. Results Forty-eight of the adolescent mothers chose Norplant, 50 chose oral contraceptives, and 2 (not further studied) chose barrier methods of contraception. The factors significantly associated with the choice of Norplant were older age (16.7 years among those who chose Norplant, vs. 16.2 years among those who chose oral contraceptives), multiparity (24 subjects vs. 6 subjects), and previous use of oral contraceptives (34 subjects vs. 21 subjects). During follow-up, there were no differences between the Norplant group an...

Adverse Childhood Experiences Expanding the Concept of Adversity

INTRODUCTION Current knowledge of Adverse Childhood Experiences (ACEs) relies on data predominantly collected from white, middle- / upper-middle-class participants and focuses on experiences within the home. Using a more socioeconomically and racially diverse urban population, Conventional and Expanded (community-level) ACEs were measured to help understand whether Conventional ACEs alone can sufficiently measure adversity, particularly among various subgroups. METHODS Participants from a previous large, representative, community-based health survey in Southeast Pennsylvania who were aged ≥18 years were contacted between November 2012 and January 2013 to complete another phone survey measuring ACEs. Ordinal logistic regression models were used to test associations between Conventional and Expanded ACEs scores and demographic characteristics. Analysis was conducted in 2013 and 2014. RESULTS Of 1,784 respondents, 72.9% had at least one Conventional ACE, 63.4% at least one Expanded ACE, and 49.3% experienced both. A total of 13.9% experienced only Expanded ACEs and would have gone unrecognized if only Conventional ACEs were assessed. Certain demographic characteristics were associated with higher risk for Conventional ACEs but were not predictive of Expanded ACEs, and vice versa. Few adversities were associated with both Conventional and Expanded ACEs. CONCLUSIONS To more accurately represent the level of adversity experienced across various sociodemographic groups, these data support extending the Conventional ACEs measure.

A human immunodeficiency virus peer education program for adolescent females

Black adolescent females living in urban environments are at high risk for human immunodeficiency virus (HIV) infection. Our objectives were to develop an HIV peer education program and to pilot-test its effect on knowledge and sexual behavior. Between September 1989 and March 1990, all females aged 12-19 years attending an inner-city, hospital-based adolescent clinic were invited to meet individually with trained peer educators (10 females aged 16-19 years) to discuss acquired immunodeficiency syndrome (AIDS) and its prevention. Each participant completed a modified version of the AIDS Knowledge and Attitudes Survey immediately before and 2-6 weeks after the counseling session. Of the 283 counseled patients, 241 (85%) completed the follow-up questionnaire and comprised the study sample. Mean age was 15.6 years, mean Hollingshead (parental occupational) score was 3.4, and 216 (90%) patients were black. Baseline knowledge about routes of transmission was high and did not improve on follow-up. Comparison of individual baseline and follow-up responses revealed improvements (p less than 0.05) in routes by which HIV is not transmitted, methods of prevention, individuals at risk, and general information about AIDS. The improvement in total score between baseline and follow-up was 38% for patients with low baseline scores, 13% for middle scores, and 3% for high scores (p less than 0.05). At baseline, 50 (21%) patients reported sexual intercourse within the preceding 2 weeks, compared to 33 (14%) at follow-up (p less than 0.05). Of the sexually active patients, 22 (44%) reported no condom use at baseline, compared to 11 (33%) at follow-up (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship Violence Among Female and Male College Undergraduate Students

OBJECTIVES To assess prevalence of victimization and perpetration of relationship violence before and during college, to explore variations by gender, and to examine differences by relationship type. DESIGN Anonymously surveyed students in 67 randomly chosen classes. SETTING Three urban college campuses. PARTICIPANTS Nine hundred ten undergraduate college students aged 17 to 22 years. MAIN OUTCOME MEASURES Self-reported victimization and perpetration of physical, emotional, and sexual violence; relationship to the victim or perpetrator. RESULTS Most (57.1%) students were female, and 58.7% were white, 16.4% black, and 15.1% Asian. Of 910 participants, 407 (44.7%) experienced partner or nonpartner violence: 383 (42.1%) reported victimization and 156 (17.1%) reported perpetration. All victimization and perpetration rates were highest before college. Emotional violence was most common before college (21.1%); during college, sexual and emotional violence were equally common (12.0% and 11.8%, respectively). Women reported more victimization than men, but male victimization was considerable (27.2%). More men perpetrated sexual violence; more women perpetrated physical violence. More than half (130 of 227) of the violence experienced during college was partner related. Students experiencing partner violence during college were more likely to experience physical and emotional violence and were less likely to experience sexual violence. CONCLUSIONS Relationship violence is prevalent among college students and frequently occurs before college. Emotional violence was most frequent before college; sexual and emotional violence were equally common during college. Women reported more victimization than men, but male victimization was common. Men perpetrated more sexual violence; women perpetrated more physical violence. Physical violence and emotional violence were most often committed by partners, while sexual violence was less likely to be partner related.

Depot Medroxyprogesterone Acetate or Oral Contraception in Postpartum Adolescents

Objective To compare rates of method continuation and repeat pregnancy among postpartum adolescents selecting depot medroxyprogesterone acetate or oral contraceptives (OCs). Methods A retrospective study of 161 adolescents aged 19 years and younger who gave birth at an urban teaching hospital between May 1,1994, and April 30,1995, returned to the hospitals family planning clinic within 14 weeks of delivery and chose depot medroxyprogesterone acetate (n = 111, 69%), or OC (n = 50, 31%) as their postpartum contraceptive method. Most subjects were black (99%), single (97%), and on medical assistance (85%). Data were gathered 12–18 months postpartum (mean ± standard deviation [SD] 14.5 ± 1.6 months) by telephone interview and medical record review. The main outcome measures were method continuation and repeat pregnancy. Results The mean (± SD) age at delivery was 17.8 ± 1.4 years. Variables differentiating subjects selecting depot medroxyprogesterone acetate or OC included multiparity (34% versus 12%, P < .05), mean age at first pregnancy (15.9 versus 16.6 years, P < .05), and mean age at first delivery (16.1 versus 16.9 years, P < .05), The survival curves for depot medroxyprogesterone acetate and OC continuation differed significantly (median duration of use 8.1 versus 5.4 months, respectively), but the continuation rates, at 12 months were similar (34% versus 32%). The survival curves for repeat pregnancy among subjects selecting depot medroxyprogesterone acetate differed significantly from curves of those choosing OC, with repeat pregnancy rates of 15% and 36% by 15 months. Postpartum selection of OC was the only variable entering a Cox regression model designed to predict repeat pregnancy (relative risk 3.0,95% confidence interval 1.4, 6.7). Conclusion Adolescent mothers choosing depot medroxy progesterone acetate or OC immediately postpartum face similarly high rates of method discontinuation and repeat pregnancy within 1 year.

Research ArticleAdverse Childhood Experiences: Expanding the Concept of Adversity

INTRODUCTION Current knowledge of Adverse Childhood Experiences (ACEs) relies on data predominantly collected from white, middle- / upper-middle-class participants and focuses on experiences within the home. Using a more socioeconomically and racially diverse urban population, Conventional and Expanded (community-level) ACEs were measured to help understand whether Conventional ACEs alone can sufficiently measure adversity, particularly among various subgroups. METHODS Participants from a previous large, representative, community-based health survey in Southeast Pennsylvania who were aged ≥18 years were contacted between November 2012 and January 2013 to complete another phone survey measuring ACEs. Ordinal logistic regression models were used to test associations between Conventional and Expanded ACEs scores and demographic characteristics. Analysis was conducted in 2013 and 2014. RESULTS Of 1,784 respondents, 72.9% had at least one Conventional ACE, 63.4% at least one Expanded ACE, and 49.3% experienced both. A total of 13.9% experienced only Expanded ACEs and would have gone unrecognized if only Conventional ACEs were assessed. Certain demographic characteristics were associated with higher risk for Conventional ACEs but were not predictive of Expanded ACEs, and vice versa. Few adversities were associated with both Conventional and Expanded ACEs. CONCLUSIONS To more accurately represent the level of adversity experienced across various sociodemographic groups, these data support extending the Conventional ACEs measure.

Household and community-level Adverse Childhood Experiences and adult health outcomes in a diverse urban population ☆

Adverse Childhood Experiences (ACEs), which include family dysfunction and community-level stressors, negatively impact the health and well being of children throughout the life course. While several studies have examined the impact of these childhood exposures amongst racially and socially diverse populations, the contribution of ACEs in the persistence of socioeconomic disparities in health is poorly understood. To determine the association between ACEs and health outcomes amongst a sample of adults living in Philadelphia and examine the moderating effect of Socioeconomic Status (SES) on this association, we conducted a cross-sectional survey of 1,784 Philadelphia adults, ages 18 and older, using random digit dialing methodology to assess Conventional ACEs (experiences related to family dysfunction), Expanded ACEs (community-level stressors), and health outcomes. Using weighted, multivariable logistic regression analyses along with SES stratified models, we examined the relationship between ACEs and health outcomes as well as the modifying effect of current SES. High Conventional ACE scores were significantly associated with health risk behaviors, physical and mental illness, while elevated Expanded ACE scores were associated only with substance abuse history and sexually transmitted infections. ACEs did have some differential impacts on health outcomes based on SES. Given the robust impact of Conventional ACEs on health, our results support prior research highlighting the primacy of family relationships on a childs life course trajectory and the importance of interventions designed to support families. Our findings related to the modifying effect of SES may provide additional insight into the complex relationship between poverty and childhood adversity.

Religiosity As a Protective Factor Against HIV Risk Among Young Transgender Women

PURPOSE Young transgender women (YTW) face many challenges to their well-being, including homelessness, joblessness, victimization, and alarming rates of HIV infection. Little has been written about factors that might help in preventing HIV in this population. Our objective was to examine the role of religion in the lives of YTW and its relationship to HIV risk. METHODS This study is derived from baseline data collected for an HIV prevention intervention. A convenience sample of YTW aged 16-25 years from Chicago were recruited consecutively and completed an audio computer-assisted self-interview. Logistic regression models were used to evaluate the relationship between sexual risk taking (sex work, multiple anal sex partners, unprotected receptive anal sex), alcohol use, formal religious practices (service attendance, reading/studying scripture), and God consciousness (prayer, thoughts about God). RESULTS A total of 92 YTW participated in the study, their mean age being 20.4 years; 58% were African American, 21% white, and 22% other. On multivariate logistic regression, alcohol use was significantly associated with sexual risk in both models, with adjusted odds ratio (OR) of 5.28 (95% confidence intervals [CI]: 1.96-14.26) in the Formal Practices model and 3.70 (95% CI: 1.53-8.95) in the God Consciousness model. Controlling for alcohol use, it was found that Formal Practices was significantly associated with sexual risk (OR = .29, 95% CI: .11-.77), but God Consciousness was not (OR = .60, 95% CI: .25-1.47). CONCLUSION Among YTW, formal religious practices may attenuate sexual risk-taking behaviors and therefore HIV risk. Further research is needed to explore the role of the religion in the lives of YTW as a protective asset.

Important health provider characteristics: the perspective of urban ninth graders.

ABSTRACT. Clinicians caring for adolescents may be better positioned to provide health care when equipped with an understanding of adolescents’ preferences regarding provider characteristics. The purpose of this study is to obtain a manageable framework of adolescents’ concerns about health care providers. A series of qualitative and quantitative data-collection methods were used to elicit and organize ideas about health care providers from ninth-grade students in Philadelphia. A 5-point Likert survey, based on ideas generated and prioritized in earlier qualitative stages, was administered in school. Exploratory and confirmatory factor analysis was used to uncover latent factors. A total of 2602 students returned usable surveys. A confirmatory factor analysis model including four latent factors (patient’s interpersonal relationship with provider, concern for physical safety, concern for emotional safety, and provider counseling ability) explained 51.6% of the model variability. Urban ninth graders want providers with whom they can develop strong relationships, feel emotionally and physically safe, and turn to for counseling. Communication with adolescent-aged patients should be a standard component of health care training and should promote provider sensitivity to adolescent fears and needs in the health care setting.

Adolescent suicide attempters: Do physicians recognize them?

The single most important risk factor for adolescent suicide is a previous attempt. It is unclear if physicians can identify adolescents who have attempted suicide. Our objectives were to determine the prevalence of previous attempts in an adolescent clinic population, if physicians identify attempters, and if attempters demonstrate persistent distress. Of 332 patients aged 12-19 years attending a medical clinic, 48 (14.5%) reported a previous attempt. The physicians visit note documented that only 8 (16.7%) of the 48 attempters were asked about suicidal behavior. Attempters were more likely than nonattempters (p less than 0.05) to be female; to come to clinic without a guardian; to give a chief complaint pertaining to sexually transmitted disease, obstetrics-gynecology, or mental health; and to report previous mental health care. Attempters had poorer mean scores (p less than 0.05) on validated subscales for family relationships, social competence, depression, unpopularity, somatic complaints, thought disorders, delinquency, aggression, and identity. We conclude that suicide attempts are common among adolescent clinic patients, that physicians may not recognize attempters, and that attempters remain distressed and in need of care. Physicians who see adolescents for routine medical problems must consider the potential for self-destructive behavior, regardless of the presenting complaint.