Debra Kalmuss

Race/Ethnicity and Women’s Use of Complementary and Alternative Medicine in the United States: Results of a National Survey

OBJECTIVES We studied the use of complementary and alternative medicine (CAM) among women in 4 racial/ethnic groups: non-Hispanic Whites, African Americans, Mexican Americans, and Chinese Americans. METHODS We obtained a nationally representative sample of women aged 18 years and older living in the United States in 2001. Oversampling obtained 800 interviews in each group, resulting in a sample of 3068 women. RESULTS Between one third and one half of the members of all groups reported using at least 1 CAM modality in the year preceding the survey. In bivariate analyses, overall CAM use among Whites surpassed that of other groups; however, when CAM use was adjusted for socioeconomic factors, use by Whites and Mexican Americans were equivalent. Despite the socioeconomic disadvantage of African American women, socioeconomic factors did not account for differences in CAM use between Whites and African Americans. CONCLUSIONS CAM use among racial/ethnic groups is complex and nuanced. Patterns of CAM use domains differ among groups, and multivariate models of CAM use indicate that ethnicity plays an independent role in the use of CAM modalities, the use of CAM practitioners, and the health problems for which CAM is used.

Parenting Expectations, Experiences, and Adjustment to Parenthood: A Test of the Violated Expectations Framework.

This study assessed the effects of violated parenting expectations on the adjustment to parenthood in a sample of 473 married, middle-class, white women pregnant with their first child. The women were interviewed during the final trimester of pregnancy and at one year post-birth. The bivariate results indicated that womens expectations about how parenting would affect their lives and how they would fare in the maternal role did not match their experiences, although the magnitude of the discrepancies was small. In general, women expected things to be better at one year post-birth than they actually were. The multivariate results indicated that these discrepancies significantly affected the ease of their adjustment to motherhood. Adjustment was more difficult when parenting expectations exceeded experiences in the following domains: relationship with spouse, physical well-being, maternal competence, and maternal satisfaction. In addition, high expectations regarding child care assistance from spouse, and support from extended family, were associated with a more difficult period of adjustment, net of the actual amount of assistance or support received. The transition to parenthood is a major life event with long-term consequences for individuals in families. As such it is one of the most commonly studied transitions in the life cycle. Early work in this area suggested that entry into parenthood precipitated a crisis for the family unit (Dyer, 1963; Hill, 1949; LeMasters, 1957). However, researchers found little empirical support for this view of parenthood (Hobbs, 1965; Hobbs & Cole, 1976; Hobbs & Wimbish, 1977; Russell, 1974). They thus rejected the notion of crisis, and offered an alternative conceptualization of the entry into parenthood as a transition associated with the experience of stress as well as the satisfactions and rewards of parenting (Hobbs & Cole, 1976; Jacoby, 1969; Rossi, 1968; Russell, 1974). While research in this area originated as an attempt to understand the nature of the transition and its effect on individuals as well as the family unit, the scope of this work has shifted over time to an almost exclusive focus on how becoming a parent affects the marital relationship. This work has generally found declines in marital satisfaction across the transition to parenthood (Belsky, Lang, & Rovine, 1985; Belsky & Pensky, 1988; Belsky & Rovine, 1990; Cowan et al., 1985; Glenn & McLanahan, 1982; Goldberg, Michaels, & Lamb, 1985; Miller & Sollie, 1980; Ryder, 1973). This finding has held across a variety of research designs that have progressively become more reCenter for Population and Family Health, 60 Haven Avenue B-3, Columbia University, New York, NY 10032.

Initiation of oral contraceptives using a quick start compared with a conventional start: a randomized controlled trial.

OBJECTIVE: To estimate whether young women taking the first pill on the day of prescription had higher continuation rates and lower pregnancy rates than women who waited until menses to start the oral contraceptive pill (OCP). METHODS: We recruited 1,716 women aged younger than 25 years seeking to initiate the oral contraceptive at three publicly funded family planning clinics, and randomly assigned them to conventional initiation of the pill (conventional start) or immediate, directly observed ingestion of the first pill (quick start) during the clinic visit. Women underwent follow-up interviews at 3 and 6 months. RESULTS: Sixty percent of participants discontinued the pill, and 8% became pregnant during follow-up. Women who took the first pill in the clinic were more likely to continue to the second OCP pack (odds ratio 1.5, 95% confidence interval 1.0–2.1.); however, the Quick Start approach did not improve OCP continuation rates at 3 and 6 months. Those assigned to Quick Start were slightly less likely to become pregnant within 6 months from the time they started the pill (hazard ratio 0.90, 95% confidence interval 0.64—1.25). Eighty-one percent of women rated the Quick Start approach as acceptable or preferable to waiting. Rates of serious adverse events were low and similar in the two groups. CONCLUSION: Protocols that require a woman to wait until the next menses to start hormonal contraceptives are an obstacle to contraceptive initiation. Directly observed, immediate initiation of the pill improves short-term continuation. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00068848 LEVEL OF EVIDENCE: I

Preventing sexual risk behaviors and pregnancy among teenagers: linking research and programs.

Recent trends in adolescent sexual behavior offer mixed messages. It is very encouraging that teenagers’ overall rates of sexual activity, pregnancy and childbearing are decreasing, and that their rates of contraceptive and condom use are increasing. 1 However, the proportion of young people who have had sex at an early age has increased. 2 Moreover, while adolescent females’ contraceptive use at first sex is rising, their use at most recent sex is falling. 3 There is general consensus that the proportion of teenagers who engage in behaviors that put them at risk of pregnancy and of HIV and other sexually transmitted infections (STIs) remains too high. Each year, approximately one million young women aged 15–19—or one-fifth of all sexually active females in this age-group—become pregnant; the vast majority of these pregnancies are unplanned. 4 In the United States, the risk of acquiring an STI is higher among teenagers than among adults. 5 Moreover, rates of unprotected sexual activity, STIs, pregnancy and childbearing continue to be substantially higher among U.S. adolescents than among young people in comparable industrialized countries. 6 Research has also begun to highlight an alarmingly high rate of involuntary sex among young people. In the 1995 National Survey of Family Growth, 13% of 15–19-year-old females reported that they had been forced to have sex. 7 When asked about their first sexual experience, 22% of 15–44-year-old women for whom it occurred before age 15 reported that the act was involuntary, as did 16% of those who first had sex before age 16. Involuntary sexual activity is typically unprotected and thus puts its victims at very high risk of pregnancy and STIs. Finally, recent research and clinical observations suggest that a substantial proportion of teenagers, including those who report having never had vaginal sex, are engaging in oral sex. 8 This trend has negative implications for teenagers’ sexual health because many seem unaware that STIs can be acquired through unprotected oral sex.

Depressive symptoms and Depo-Provera.

Women enrolled in a multicenter prospective study were evaluated to identify any possible relationship between depressive symptoms and the use of contraceptives. Women choosing Depo-Provera (n = 495) were evaluated before starting these contraceptives and were reinterviewed 1 year later. Women who continued the method had lower depressive symptom scores at baseline than did the women who discontinued the method or who were lost to follow-up. Among the continuing Depo-Provera users, the depressive symptom scores improved slightly at 1 year (7.4 vs 6.7). Those subjects with the highest (i.e., worst) scores at enrollment demonstrated improved scores at follow-up.

Patterns of Men’s Use of Sexual and Reproductive Health Services

CONTEXT Men have been neglected as a target population for sexual and reproductive health services. As a result, little is known about the rates and antecedents of mens service utilization. METHODS Data from the 2002 National Survey of Family Growth were used to examine utilization of sexual and reproductive health services among 3,611 men aged 20-44 who had ever had sex with a woman. Associations between demographic and behavioral variables and measures of service utilization were assessed in univariate and logistic regression analyses. RESULTS Only 48% of men reported receiving sexual and reproductive health services in the past year. The testicular exam was the most commonly received service (35%), but half of men who had had a testicular exam had received no other sexual and reproductive health services. Levels of unmet need for services among men engaging in sexual risk behaviors were substantial (32-63%). The odds of having received nontesticular services were elevated among men who were nonwhite and older, engaged in sexual risk behaviors, had had a physical exam and had public health insurance. The odds of having received only a testicular exam were elevated among men who were white, had lower levels of sexual risk, had had a physical exam and had private or no insurance. CONCLUSIONS Men who have sex with women are not receiving adequate levels of sexual and reproductive health care, and the care they receive is neither comprehensive nor integrated. Standards of clinical care need to be defined and communicated to men and providers.

Condom Use Among Women Choosing Long-Term Hormonal Contraception

CONTEXT Women who rely on long-term hormonal contraception may neglect to use condoms, and thus increase their risk of contracting sexually transmitted diseases, including AIDS. METHODS Data from a prospective, multisite study were collected to examine the probability of condom use among 1,073 new users of either the contraceptive implant or injectable; users were interviewed when they accepted their method and again six months to one year later. Multivariate logistic regression analyses identified factors that significantly predicted the likelihood of dual method use. RESULTS Condom use dropped markedly among women who adopted long-term hormonal contraception. The proportion who always used condoms in the previous three months fell from 21% at the time of adoption to 11% at follow-up. Among women with one sexual partner, this decrease was from 20% to 10%; however, among those with more than one partner, use increased from 25% to 31%. The factors significantly predicting dual method use included previous condom use (odds ratio of 2.5), receipt of AIDS-specific counseling (odds ratio of 1.6), the perception of being at some risk of AIDS at baseline (odds ratio of 1.4) and having had more than one sexual partner over the study period (odds ratio of 5.4). In addition, injectable users, teenagers and black women were more likely than other women to use condoms with their hormonal method. CONCLUSIONS Although condom use among all women declined markedly once they initiated long-term hormonal contraception, frequency of condom use varied by subgroup and was associated with several factors. Most importantly, women with more than one sexual partner and those who received a message during counseling on the need to continue using condoms were more likely than others to use condoms in conjunction with the implant or injectable.

Medical Pluralism among American Women: Results of a National Survey

BACKGROUND Medical pluralism can be defined as the employment of more than one medical system or the use of both conventional and complementary and alternative medicine (CAM) for health and illness. American women use a variety of health services and practices for womens health conditions, yet no national study has specifically characterized womens medical pluralism. Our objective was to describe medical pluralism among American women. METHODS A nationally representative telephone survey of 808 women >or=18 years of age was conducted in 2001. Cross-sectional observations of the use of 11 CAM domains and the use of an additional domain--spirituality, religion, or prayer for health--during the past year are reported. Womens health conditions, treatments used, reasons for use, and disclosure to conventional physicians are described, along with predictors of CAM use. RESULTS Over half (53%) of respondents used CAM for health conditions, especially for those involving chronic pain. The majority of women disclosed such practices at clinical encounters with conventional providers. Biologically based CAM therapies, such as nutritional supplements and herbs, were commonly used with prescription and over-the-counter (OTC) pharmaceuticals for health conditions. CONCLUSIONS Medical pluralism is common among women and should be accepted as a cultural norm. Although disclosure rates of CAM use to conventional providers were higher than in previous population-based studies, disclosure should be increased, especially for women who are pregnant and those with heart disease and cancer. The health risks and benefits of polypharmacy should be addressed at multiple levels of the public health system.

Determinants of early implant discontinuation among low-income women.

The determinants of contraceptive implant discontinuation within six months of insertion were examined among 786 low-income women attending family planning clinics in three U.S. cities. The six-month cumulative life-table discontinuation rate was 7.6%. Menstrual side effects were the most common reasons given for early implant removal, although women who discontinued use were no more likely than those who continued with the method to report menstrual irregularities. Women who opted for early removal were more likely than those who continued with the method to experience headaches, hair loss, weight gain and arm infection. Logistic regression analysis indicates that dissatisfaction with prior contraceptive methods, a partner who wants a child within the next two years, perceived pressure from health care providers to choose the implant, exposure to negative media coverage and the number of implant side effects significantly predict early implant discontinuation. Womens social and demographic characteristics, Medicaid status and motivation to avoid an unplanned pregnancy were not significantly related to early removal.

Injectable contraceptive discontinuation and subsequent unintended pregnancy among low-income women.

OBJECTIVES This study investigated rates of discontinuation of the recently introduced injectable contraceptive depot medroxyprogesterone acetate (DMPA) and postdiscontinuation rates of unprotected intercourse and unintended pregnancy. METHODS A sample of 402 low-income, urban, minority women were interviewed when they initiated DMPA use and 12 months later. RESULTS The 12-month life-table discontinuation rate was 58%, with half of the discontinuers stopping after only one injection. Menstrual changes and other side effects were the most frequently cited reasons for discontinuation. Approximately half of the discontinuers at risk for unintended pregnancy either did not make the transition to another contraceptive or used contraception only sporadically. The cumulative unintended pregnancy rate by 9 months postdiscontinuation was 20%. CONCLUSIONS DMPA initiators were at substantial risk for unintended pregnancy because most quickly discontinued use and did not make the transition to consistent use of another contraceptive.