David E. Kanouse

A National Survey of Stress Reactions after the September 11, 2001, Terrorist Attacks

BACKGROUND People who are not present at a traumatic event may also experience stress reactions. We assessed the immediate mental health effects of the terrorist attacks on September 11, 2001. METHODS Using random-digit dialing three to five days after September 11, we interviewed a nationally representative sample of 569 U.S. adults about their reactions to the terrorist attacks and their perceptions of their childrens reactions. RESULTS Forty-four percent of the adults reported one or more substantial stress symptoms; 91 percent had one or more symptoms to at least some degree. Respondents throughout the country reported stress syndromes. They coped by talking with others (98 percent), turning to religion (90 percent), participating in group activities (60 percent), and making donations (36 percent). Eighty-five percent of parents reported that they or other adults in the household had talked to their children about the attacks for an hour or more; 34 percent restricted their childrens television viewing. Thirty-five percent of children had one or more stress symptoms, and 47 percent were worried about their own safety or the safety of loved ones. CONCLUSIONS After the September 11 terrorist attacks, Americans across the country, including children, had substantial symptoms of stress. Even clinicians who practice in regions that are far from the recent attacks should be prepared to assist people with trauma-related symptoms of stress.

Watching Sex on Television Predicts Adolescent Initiation of Sexual Behavior

Background. Early sexual initiation is an important social and health issue. A recent survey suggested that most sexually experienced teens wish they had waited longer to have intercourse; other data indicate that unplanned pregnancies and sexually transmitted diseases are more common among those who begin sexual activity earlier. The American Academy of Pediatrics has suggested that portrayals of sex on entertainment television (TV) may contribute to precocious adolescent sex. Approximately two-thirds of TV programs contain sexual content. However, empirical data examining the relationships between exposure to sex on TV and adolescent sexual behaviors are rare and inadequate for addressing the issue of causal effects. Design and Participants. We conducted a national longitudinal survey of 1792 adolescents, 12 to 17 years of age. In baseline and 1-year follow-up interviews, participants reported their TV viewing habits and sexual experience and responded to measures of more than a dozen factors known to be associated with adolescent sexual initiation. TV viewing data were combined with the results of a scientific analysis of TV sexual content to derive measures of exposure to sexual content, depictions of sexual risks or safety, and depictions of sexual behavior (versus talk about sex but no behavior). Outcome Measures. Initiation of intercourse and advancement in noncoital sexual activity level, during a 1-year period. Results. Multivariate regression analysis indicated that adolescents who viewed more sexual content at baseline were more likely to initiate intercourse and progress to more advanced noncoital sexual activities during the subsequent year, controlling for respondent characteristics that might otherwise explain these relationships. The size of the adjusted intercourse effect was such that youths in the 90th percentile of TV sex viewing had a predicted probability of intercourse initiation that was approximately double that of youths in the 10th percentile, for all ages studied. Exposure to TV that included only talk about sex was associated with the same risks as exposure to TV that depicted sexual behavior. African American youths who watched more depictions of sexual risks or safety were less likely to initiate intercourse in the subsequent year. Conclusions. Watching sex on TV predicts and may hasten adolescent sexual initiation. Reducing the amount of sexual content in entertainment programming, reducing adolescent exposure to this content, or increasing references to and depictions of possible negative consequences of sexual activity could appreciably delay the initiation of coital and noncoital activities. Alternatively, parents may be able to reduce the effects of sexual content by watching TV with their teenaged children and discussing their own beliefs about sex and the behaviors portrayed. Pediatricians should encourage these family discussions.

Does Watching Sex on Television Predict Teen Pregnancy? Findings From a National Longitudinal Survey of Youth

OBJECTIVE. There is increasing evidence that youth exposure to sexual content on television shapes sexual attitudes and behavior in a manner that may influence reproductive health outcomes. To our knowledge, no previous work has empirically examined associations between exposure to television sexual content and adolescent pregnancy. METHODS. Data from a national longitudinal survey of teens (12–17 years of age, monitored to 15–20 years of age) were used to assess whether exposure to televised sexual content predicted subsequent pregnancy for girls or responsibility for pregnancy for boys. Multivariate logistic regression models controlled for other known correlates of exposure to sexual content and pregnancy. We measured experience of a teen pregnancy during a 3-year period. RESULTS. Exposure to sexual content on television predicted teen pregnancy, with adjustment for all covariates. Teens who were exposed to high levels of television sexual content (90th percentile) were twice as likely to experience a pregnancy in the subsequent 3 years, compared with those with lower levels of exposure (10th percentile). CONCLUSIONS. This is the first study to demonstrate a prospective link between exposure to sexual content on television and the experience of a pregnancy before the age of 20. Limiting adolescent exposure to the sexual content on television and balancing portrayals of sex in the media with information about possible negative consequences might reduce the risk of teen pregnancy. Parents may be able to mitigate the influence of this sexual content by viewing with their children and discussing these depictions of sex.

The Appropriateness of Recommendations for Hysterectomy

Objective To evaluate the appropriateness of recommendations for hysterectomies done for nonemergency and non-oncologic indications. Methods We assessed the appropriateness of recommendations for hysterectomy for 497 women who had the operation between August 1993 and July 1995 in one of nine capitated medical groups in Southern California. Appropriateness was assessed using two sets of criteria, the first developed by a multispecialty expert physician panel using the RAND/University of California–Los Angeles appropriateness method, and the second consisting of the ACOG criteria sets for hysterectomies. The main outcome measure was the appropriateness of recommendation for hysterectomy, based on expert panel ratings and ACOG criteria sets. Results The most common indications for hysterectomy were leiomyomata (60% of hysterectomies), pelvic relaxation (11%), pain (9%), and bleeding (8%). Three hundred sixty-seven (70%) of the hysterectomies did not meet the level of care recommended by the expert panel and were judged to be recommended inappropriately. ACOG criteria sets were applicable to 71 women, and 54 (76%) did not meet ACOG criteria for hysterectomy. The most common reasons recommendations for hysterectomies considered inappropriate were lack of adequate diagnostic evaluation and failure to try alternative treatments before hysterectomy. Conclusion Hysterectomy is often recommended for indications judged inappropriate. Patients and physicians should work together to ensure that proper diagnostic evaluation has been done and appropriate treatments considered before hysterectomy is recommended.

Perceived Discrimination in Clinical Care in a Nationally Representative Sample of HIV‐Infected Adults Receiving Health Care

BACKGROUND: Perceived discrimination in clinical settings could discourage HIV-infected people from seeking health care, adhering to treatment regimens, or returning for follow-up.OBJECTIVES: This study aims to determine whether HIV-infected people perceive that physicians and other health care providers have discriminated against them.DESIGN, PARTICIPANTS: Cross-sectional data (1996 to 1997) from the HIV Cost and Services Utilization Study (HCSUS), which conducted in-person interviews with a nationally representative probability sample of 2,466 HIV-infected adults receiving health care within the contiguous U.S.MEASUREMENTS: Reports of whether health care providers have been uncomfortable with the respondent, treated the respondent as an inferior, preferred to avoid the respondent, or refused the respondent service. Questions also covered the types of providers who engaged in these behaviors.RESULTS: Twenty-six percent of HIV-infected adults receiving health care reported experiencing at least 1 of 4 types of perceived discrimination by a health care provider since becoming infected with HIV, including 8% who had been refused service. White respondents (32%) were more likely than others (27%) and Latinos (21%) and nearly twice as likely as African Americans (17%) to report perceived discrimination (P<.001). Respondents whose first positive HIV test was longer ago were also more likely to report discrimination (P<.001). Respondents who reported discrimination attributed it to physicians (54%), nurses and other clinical staff (39%), dentists (32%), hospital staff (31%), and case managers or social workers (8%).CONCLUSIONS: Many HIV-infected adults believe that their clinicians have discriminated against them. Clinicians should make efforts to address circumstances that lead patients to perceive discrimination, whether real or imagined.

Sex Without Disclosure of Positive HIV Serostatus in a US Probability Sample of Persons Receiving Medical Care for HIV Infection

OBJECTIVES We estimated the proportion of HIV-positive adults who have any sexual contact without disclosure and the proportion of their sexual partnerships that involve unprotected sex without disclosure. METHODS We drew participants from the HIV Cost and Services Utilization Study (n = 1421). Interviews assessed disclosure and sexual activities with up to 5 recent partners. RESULTS Overall, 42% of the gay or bisexual men, 19% of the heterosexual men, and 17% of all the women reported any sex without disclosure, predominately within nonexclusive partnerships (P <.001). Across all groups, 13% of serodiscordant partnerships involved unprotected anal or vaginal sex without disclosure, with no significant difference between groups. CONCLUSIONS Risky sex without disclosure of serostatus is not uncommon among people with HIV.

HIV-infected parents and their children in the United States.

OBJECTIVES This study sought to determine the number, characteristics, and living situations of children of HIV-infected adults. METHODS Interviews were conducted in 1996 and early 1997 with a nationally representative probability sample of 2864 adults receiving health care for HIV within the contiguous United States. RESULTS Twenty-eight percent of infected adults in care had children. Women were more likely than men to have children (60% vs 18%) and to live with them (76% vs 34%). Twenty-one percent of parents had been hospitalized during the previous 6 months, and 10% had probably been drug dependent in the previous year. Parents continued to have children after being diagnosed with HIV: 12% of all women conceived and bore their youngest child after diagnosis, and another 10% conceived before but gave birth after diagnosis. CONCLUSIONS Clinical and support services for people affected by the HIV epidemic should have a family focus.

Complementary and Alternative Medicine Use and Substitution for Conventional Therapy by HIV-infected Patients

Background: HIV‐infected patients commonly use complementary and alternative medicine (CAM), but it is not known how often CAM is used as a complement or as a substitute for conventional HIV therapy. Objectives: To evaluate the prevalence and factors associated with CAM use with potential for adverse effects and CAM substitution for conventional HIV medication. Design and Participants: Cross‐sectional survey of U.S. national probability sample of HIV‐infected patients (2,466 adults) in care from December 1996 to July 1997. Main Outcome Variables: Any CAM use, CAM use with potential for adverse effects, and use of CAM as a substitute for conventional HIV therapy. Substitution was defined as replacement of some or all conventional HIV medications with CAM. Results: Fifty‐three percent of patients had recently used at least one type of CAM. One quarter of patients used CAM with the potential for adverse effects, and one‐third had not discussed such use with their health care provider. Patients with a greater desire for medical information and involvement in medical decision making and with a negative attitude toward antiretrovirals were more likely to use CAM. Three percent of patients substituted CAM for conventional HIV therapy. They were more likely to desire involvement in medical decision‐making (odds ratio, 1.8; 95% confidence interval, 1.0‐3.2) and to have a negative attitude toward antiretrovirals (odds ratio, 7.8; 95% confidence interval, 3.0‐19.0). Conclusions: Physicians should openly ask HIV‐infected patients about CAM use to prevent adverse effects and to identify CAM substitution for conventional HIV therapy.

Derivation and properties of a brief health status assessment instrument for use in HIV disease

Health status measures adapted from the Medical Outcomes Study (MOS) scales have been shown to be useful and highly reliable in human immunodeficiency virus-infected populations, but acceptance of these measures has been limited in part by concerns over investigator, patient, and data burden. We sought to address these concerns by reducing the number of items in the MOS scales rather than by reducing the number of domains covered. We selected items for the shorter scales based on the static and dynamic relationships to the longer scales and to indicators of clinical and functional status in 10,399 responses from 1,934 participants, as well as in relevant subpopulations. The resulting scales have a total of 21 items, as compared to 38 in the longer instrument. Correlations between the shorter and longer scales were excellent. At 0.78 to 0.85, the reliability of the subscales was lower than that of the full scales. However, compared to an index based on the longer scales, an index based on the subscales had identical reliability, yielded nearly identical values, and was as sensitive in detecting treatment differences in a clinical trial. The resulting instrument continues to cover disability, work, utilization, and health status, but is less than half the length of our previous comprehensive questionnaires.

Perceived Racial/Ethnic Discrimination Among Fifth-Grade Students and Its Association With Mental Health

OBJECTIVES We sought to describe the prevalence, characteristics, and mental health problems of children who experience perceived racial/ethnic discrimination. METHODS We analyzed cross-sectional data from a study of 5147 fifth-grade students and their parents from public schools in 3 US metropolitan areas. We used multivariate logistic regression (overall and stratified by race/ethnicity) to examine the associations of sociodemographic factors and mental health problems with perceived racial/ethnic discrimination. RESULTS Fifteen percent of children reported perceived racial/ethnic discrimination, with 80% reporting that discrimination occurred at school. A greater percentage of Black (20%), Hispanic (15%), and other (16%) children reported perceived racial/ethnic discrimination compared with White (7%) children. Children who reported perceived racial/ethnic discrimination were more likely to have symptoms of each of the 4 mental health conditions included in the analysis: depression, attention deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder. An association between perceived racial/ethnic discrimination and depressive symptoms was found for Black, Hispanic, and other children but not for White children. CONCLUSIONS Perceived racial/ethnic discrimination is not an uncommon experience among fifth-grade students and may be associated with a variety of mental health disorders.