Jeannette R. Ickovics

Relationship of subjective and objective social status with psychological and physiological functioning : preliminary data in healthy white women

This preliminary study compared the associations between objective and subjective socioeconomic status (SES) with psychological and physical variables among 157 healthy White women, 59 of whom subsequently participated in a laboratory stress study. Compared with objective indicators, subjective social status was more consistently and strongly related to psychological functioning and health-related factors (self-rated health, heart rate, sleep latency, body fat distribution, and cortisol habituation to repeated stress). Most associations remained significant even after controlling for objective social status and negative affectivity. Results suggest that, in this sample with a moderately restricted range on SES and health, psychological perceptions of social status may be contributing to the SES-health gradient.

Group prenatal care and perinatal outcomes: a randomized controlled trial.

OBJECTIVE: To determine whether group prenatal care improves pregnancy outcomes, psychosocial function, and patient satisfaction and to examine potential cost differences. METHODS: A multisite randomized controlled trial was conducted at two university-affiliated hospital prenatal clinics. Pregnant women aged 14–25 years (n=1,047) were randomly assigned to either standard or group care. Women with medical conditions requiring individualized care were excluded from randomization. Group participants received care in a group setting with women having the same expected delivery month. Timing and content of visits followed obstetric guidelines from week 18 through delivery. Each 2-hour prenatal care session included physical assessment, education and skills building, and support through facilitated group discussion. Structured interviews were conducted at study entry, during the third trimester, and postpartum. RESULTS: Mean age of participants was 20.4 years; 80% were African American. Using intent-to-treat analyses, women assigned to group care were significantly less likely to have preterm births compared with those in standard care: 9.8% compared with 13.8%, with no differences in age, parity, education, or income between study conditions. This is equivalent to a risk reduction of 33% (odds ratio 0.67, 95% confidence interval 0.44–0.99, P=.045), or 40 per 1,000 births. Effects were strengthened for African-American women: 10.0% compared with 15.8% (odds ratio 0.59, 95% confidence interval 0.38–0.92, P=.02). Women in group sessions were less likely to have suboptimal prenatal care (P<.01), had significantly better prenatal knowledge (P<.001), felt more ready for labor and delivery (P<.001), and had greater satisfaction with care (P<.001). Breastfeeding initiation was higher in group care: 66.5% compared with 54.6%, P<.001. There were no differences in birth weight nor in costs associated with prenatal care or delivery. CONCLUSION: Group prenatal care resulted in equal or improved perinatal outcomes at no added cost. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00271960 LEVEL OF EVIDENCE: I

Adherence in AIDS clinical trials : A framework for clinical research and clinical care

Assessment of adherence within AIDS clinical trials is a critical component of the successful evaluation of therapeutic outcomes. Poor medication adherence can result in the misinterpretation of clinical trial data. Research on factors affecting adherence in AIDS clinical trials has been scarce, and few investigations have evaluated strategies for enhancing patient participation. One reason may be the absence of a conceptual framework to guide research. Consistent with previous research on medical adherence, we propose a framework whereby factors affecting adherence in AIDS clinical trials can be categorized as characteristics of the: (a) individual, (b) treatment regimen, (c) patient-provider relationship, (d) clinical setting, and (e) disease. This framework is used as a heuristic for reviewing studies that examine factors affecting adherence in AIDS clinical trials. Suggestions for future research and clinical intervention are provided. These efforts are timely because adherence is now the center of attention in discourse about the efficacy of the new class of protease inhibitor drugs; non-adherence has been linked to viral resistance and drug failure. Efforts to identify factors that influence adherence to AIDS clinical trials can inform future attempts to improve adherence and retention. Better adherence protects the scientific integrity of AIDS clinical trials, promoting more efficient and accurate evaluations of therapeutic value. Accelerated access to new treatments may follow, ultimately enhancing patient care.

Psychosocial factors and surgical outcomes: an evidence-based literature review.

Abstract The influence of psychosocial factors on clinical outcomes after surgery has been investigated in several studies. This review is limited to surgical outcomes studies published between 1990 and 2004 that include (1) psychosocial variables (eg, depression, social support) as predictors of outcome and that focus on (2) clinical outcomes (eg, postoperative pain, functional recovery) using (3) specific multivariate analytic techniques with (4) relevant clinical variables (eg, presurgical health status) included as covariates. Twenty‐nine studies met these criteria. Results indicate that psychosocial factors play a significant role in recovery and are predictive of surgical outcome, even after accounting for known clinical factors. Attitudinal and mood factors were strongly predictive; personality factors were least predictive. The results suggest that preoperative consideration of attitudinal and mood factors will assist the surgeon in estimating both the speed and extent of postoperative recovery.

Women's health: Review and research agenda as we approach the 21st century.

This article reviews past research and projects future research directions regarding womens health. Sex differences in mortality and morbidity, along with evidence that the quality and quantity of these differences are changing, are examined. Over the past decade, concurrent with dramatic changes in lifestyle and social roles for women, mortality rates have shifted, resulting in a decreasing advantage for women. Explaining the consequences of these dynamic changes requires understanding the health effects of such variables as perceived control, the experience of life roles, perceived and actual social support, and redefinition of gender roles. The future portends additional changes that will significantly affect womens health. In establishing an explicit psychological research agenda on womens health, (a) general recommendations for research are provided and (b) important issues that have not yet received a great deal of research attention (e.g., women and AIDS, psychopharmacology, reproductive technologies) are highlighted. This article expands the current discourse in health psychology and raises a number of issues for serious consideration.

Women and AIDS in the United States: epidemiology, natural history, and mediating mechanisms.

The number and proportion of women with the human immunodeficiency virus (HIV)1 and acquired immunodeficiency syndrome (AIDS) have increased rapidly throughout the past decade. Despite these increases, research attention on women with AIDS has been relatively scarce until recently. It is likely that there are important sex differences at all phases of the disease process-from prevention, through viral exposure, diagnosis, and living with HIV, to treatment for AIDS. Therefore, research findings from studies of men may not all be extended reliably to women with HIV and AIDS. In this article, we review the literature on U.S. women in particular and discuss what differentiates these women from their male counterparts with the disease. We begin with an epidemiologic review and description of the natural history of the disease to lay the foundation for a more complete understanding of the biological and psychosocial factors relevant to AIDS in women. The association between psychosocial mechanisms--including stress, control, and social support--and immune-mediated disease outcomes is discussed in detail. Implications for research, prevention, and treatment also are considered.

Adherence to HAART among patients with HIV: Breakthroughs and barriers

Highly active antiretroviral therapy (HAART) has been a major breakthrough for the treatment of patients with HIV; however, adherence to treatment remains a formidable barrier. This paper evaluates the current state-of-the-science in adherence to HAART. Barriers to treatment success, determinants of adherence and interventions to improve adherence are reviewed. Overall, multifaceted interventions appear most promising. We conclude with recommendations to enhance clinical practice and improve treatment outcomes for patients with HIV. Despite substantial attention to adherence in recent years, much more remains to be done to understand and promote adherence to HAART.

The intergenerational cycle of teenage motherhood: An ecological approach.

OBJECTIVE Daughters of teenage mothers have increased risk for teenage childbearing, perpetuating intergenerational cycles. Using Ecological Systems Theory, this study prospectively examined risk factors for teenage childbearing among a national sample of adolescent girls. DESIGN Data came from the National Longitudinal Survey of Youth 1997. Participants (N = 1,430) were recruited in early adolescence and interviewed yearly for 6 years. Survival analysis was used to examine the rate of childbirth across the teenage years by maternal age at first birth. Hierarchical Cox regression was used to identify multivariate predictors of teenage childbearing and to test whether risk factors differed between daughters of teenage versus older mothers. PRIMARY OUTCOME MEASURE Age at first childbirth was based on cumulative information collected at yearly interviews. RESULTS Daughters of teenage mothers were 66% more likely to become teenage mothers, after accounting for other risks. Individual (school performance), family (maternal education, marital status, number of children), peer (dating history), and environmental (race, enrichment) factors predicted teenage childbearing. Risks unique to daughters of teenage mothers were deviant peer norms, low parental monitoring, Hispanic race, and poverty. CONCLUSION Results support multidimensional approaches to pregnancy prevention, and targeted interventions addressing unique risk factors among daughters of teenage mothers.

Urban Teens: Trauma, Posttraumatic Growth, and Emotional Distress among Female Adolescents.

Urban teens face many traumas, with implications for potential growth and distress. This study examined traumatic events, posttraumatic growth, and emotional distress over 18 months among urban adolescent girls (N = 328). Objectives were to (a) describe types of traumatic events, (b) determine how type and timing of events relate to profiles of posttraumatic growth, and (c) prospectively examine effects of event type and posttraumatic growth on short- and long-term emotional distress with controls for pre-event distress. Results indicate that type of event was related to profiles of posttraumatic growth, but not with subsequent emotional distress. When baseline emotional distress was controlled, posttraumatic growth was associated with subsequent reductions in short- and long-term emotional distress. Implications for future research and clinical practice with adolescents are addressed.

Effects of propranolol on recovery of heart rate variability following acute myocardial infarction and relation to outcome in the Beta-Blocker Heart Attack Trial.

This study evaluated the effects of propranolol on recovery of heart rate variability (HRV) after acute myocardial infarction and its relation to outcome in the Beta-blocker Heart Attack Trial (BHAT). Beta blockers improve mortality after acute myocardial infarction, but through an unknown mechanism. Depressed HRV, a measure of autonomic tone, predicts mortality after acute myocardial infarction. Whether beta blockers influence recovery of HRV after acute myocardial infarction, and thereby improve outcome, is unknown. We compared 24-hour HRV parameters at 1 week after acute myocardial infarction and after 6 weeks of treatment with propanolol (n = 88) or placebo (n = 96). The relation between 25-month outcome (death/acute myocardial infarction/congestive heart failure), propranolol treatment, and HRV was further analyzed. After 6 weeks, high-frequency (HF) power (log-normalized), an index of vagal tone, increased more in propranolol-treated patients (4.28 +/- 0.1 to 5.17 +/- 0.09 ms(2)) than in placebo-treated patients (4.26 +/- 0.09 to 4.77 +/- 0.1 ms(2), p <0.05). Sympathovagal balance measured by the low-frequency (LF) to HF ratio increased in placebo-treated patients (3.55 +/- 0.24 to 3.86 +/- 0.24) but decreased in those treated with propranolol (3.76 +/- 0.29 to 3.17 +/- 0.23, p <0.01). Other frequency-domain parameters increased over time but were not affected by propranolol. Propranolol blunted the morning increase in the LF/HF ratio. Recovery of HF, the strongest HRV predictor of outcome, and propranolol therapy independently predicted outcome. In summary, after acute myocardial infarction, propranolol therapy improves recovery of parasympathetic tone, which correlates with improved outcome, and decreases morning sympathetic predominance. These findings may elucidate the mechanisms by which beta blockers decrease mortality and reduce the early morning risk of sudden death after acute myocardial infarction.