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Racial-ethnic minorities receive lower quality and intensity of health care compared with whites across a wide range of preventive, diagnostic, and therapeutic services and disease entities. These disparities in health care contribute to continuing racial-ethnic disparities in the burden of illness and death. Several national medical organizations and the Institute of Medicine have issued position papers and recommendations for the elimination of health care disparities. However, physicians in practice are often at a loss for how to translate these principles and recommendations into specific interventions in their own clinical practices. This paper serves as a blueprint for translating principles for the elimination of racial-ethnic disparities in health care into specific actions that are relevant for individual clinical practices. We describe what is known about reducing racial-ethnic disparities in clinical practice and make recommendations for how clinician leaders can apply this evidence to transform their own practices. [ABSTRACT FROM AUTHOR]

While births may be dichotomous, fertility intentions are not inherently so. Intentions are predictions about the future and, as such, are couched in considerable uncertainty. Ignoring this uncertainty hides much of what could be learned from data on fertility intentions. This paper presents a model which allows analysis of the full range of intentions. This paper presents a model which allows analysis of the full range of intentions. After selecting a sample of women in the later stage of childbearing (e.g., those who intend fewer than two additional children) from the 1965 and 1970 National Fertility Studies, it is shown that: (1) substantial portions of women at this stage of the reproductive life cycle were indeed uncertain of their parity-specific intention; (2) this certainty, like more firm intentions, varies by age and parity as the model predicts; and (3) there were significant shifts in the level of certainty between 1965 and 1970. Specifically, while intentions for third, fourth, and fifth births declined, more women "didn't know" if they intended to have another child or not. Among those not intending another child, more seemed uncertain of this intention in 1970 than did comparable women in 1965. In contrast, those intending another child seemed more certain. These changes in intention and uncertainty indicate that the observed decline in intended parity was tentative. Post-1970 evidence suggests that this tentative decline has become an equivocal one. [ABSTRACT FROM AUTHOR]

Background: Many older adults in the U.S. do not receive appropriate colorectal cancer (CRC) screening. Although primary care physicians' recommendations to their patients are central to the screening process, little information is available about their recommendations in relation to guidelines for the menu of CRC screening modalities, including fecal occult blood testing (FOBT), flexible sigmoidoscopy (FS), colonoscopy, and double contrast barium enema (DCBE). The objective of this study was to explore potentially modifiable physician and practice factors associated with guideline-consistent recommendations for the menu of CRC screening modalities.Methods: We examined data from a nationally representative sample of 1266 physicians in the U.S. surveyed in 2007. The survey included questions about physician and practice characteristics, perceptions about screening, and recommendations for age of initiation and screening interval for FOBT, FS, colonoscopy and DCBE in average risk adults. Physicians' screening recommendations were classified as guideline consistent for all, some, or none of the CRC screening modalities recommended. Analyses used descriptive statistics and polytomous logit regression models.Results: Few (19.1%; 95% CI:16.9%, 21.5%) physicians made guideline-consistent recommendations across all CRC screening modalities that they recommended. In multivariate analysis, younger physician age, board certification, north central geographic region, single specialty or multi-specialty practice type, fewer patients per week, higher number of recommended modalities, use of electronic medical records, greater influence of patient preferences for screening, and published clinical evidence were associated with guideline-consistent screening recommendations (p < 0.05).Conclusions: Physicians' CRC screening recommendations reflect both overuse and underuse, and few made guideline-consistent CRC screening recommendations across all modalities they recommended. Interventions that focus on potentially modifiable physician and practice factors that influence overuse and underuse and address the menu of recommended screening modalities will be important for improving screening practice. [ABSTRACT FROM AUTHOR]

The increasing burden of chronic diseases in the United States presents a major challenge to the nation's primary care systems, so improving the efficacy and efficiency of patient education is an important goal. Understanding the current perspectives, practices, and needs of primary care providers should guide innovation towards this end. As a part of the authors' ongoing quality improvement work, a short internet survey was an effective method of enhancing this understanding in one health care system. With a response rate of 24.6 %, the survey revealed that primary care waiting rooms in the health system studied are not conceived of or used by providers as spaces to engage patients in health education. To change this, providers suggested using both printed and technological methods for delivering health information, primarily related to medications, diabetes, and healthy lifestyle practices. Common barriers to improvement cited by providers included diverse language and literacy backgrounds in the patient population, as well as difficulty sustaining change due to infrastructural and administrative barriers. These results suggest steps for development, implementation, and investigation of new educational interventions for patients in the local primary care context. [ABSTRACT FROM AUTHOR]

The acculturation gap-distress model purports that immigrant children acculturate faster than do their parents, resulting in an acculturation gap that leads to family and youth maladjustment. However, empirical support for the acculturation gap-distress model has been inconclusive. In the current study, 428 Mexican-American adolescents (50.2 % female) and their primary caregivers independently completed questionnaires assessing their levels of American and Mexican cultural orientation, family functioning, and youth adjustment. Contrary to the acculturation gap-distress model, acculturation gaps were not associated with poorer family or youth functioning. Rather, adolescents with higher levels of Mexican cultural orientations showed positive outcomes, regardless of their parents' orientations to either American or Mexican cultures. Findings suggest that youths' heritage cultural maintenance may be most important for their adjustment. [ABSTRACT FROM AUTHOR]

American youth are more prone to storm and stress during adolescence than are Chinese youth (e.g., American youth's engagement in school declines more). However, it is unclear why. This research examined differences in conceptions of adolescence in the United States and China. Using both open- and closed-ended measures, youth ( N = 397; 50 % female; mean age = 13.19 years) reported on their views of teens. American (vs. Chinese) youth were more likely to see adolescence as a time of decreased family responsibility along with increased individuation from parents, school disengagement, and peer orientation. Conceptions of adolescence as a time of dampened family responsibility and heightened school disengagement contributed to American (vs. Chinese) youth being less engaged in school over the seventh and eighth grades. The findings suggest that culture shapes ideas about adolescence, which contribute to differences in American and Chinese youth's engagement in school over this phase. [ABSTRACT FROM AUTHOR]

Background: Changes to national guidelines for breast and cervical cancer screening have created confusion and controversy for women and their primary care providers.Objective: To characterize women's primary health care provider attitudes towards screening and changes in practice in response to recent revisions in guidelines for breast and cervical cancer screening.Design, Setting, Participants: In 2014, we distributed a confidential web and mail survey to 668 women's health care providers affiliated with the four clinical care networks participating in the three PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) consortium breast cancer research centers (385 respondents; response rate 57.6 %).Main Measures: We assessed self-reported attitudes toward breast and cervical cancer screening, as well as practice changes in response to the most recent revisions of the U.S. Preventive Services Task Force (USPSTF) recommendations.Key Results: The majority of providers believed that mammography screening was effective for reducing cancer mortality among women ages 40-74 years, and that Papanicolaou (Pap) testing was very effective for women ages 21-64 years. While the USPSTF breast and cervical cancer screening recommendations were widely perceived by the respondents as influential, 75.7 and 41.2 % of providers (for mammography and cervical cancer screening, respectively) reported screening practices in excess of those recommended by USPSTF. Provider-reported barriers to concordance with guideline recommendations included: patient concerns (74 and 36 % for breast and cervical, respectively), provider disagreement with the recommendations (50 and 14 %), health system measurement of a provider's screening practices that use conflicting measurement criteria (40 and 21 %), concern about malpractice risk (33 and 11 %), and lack of time to discuss the benefits and harms with their patients (17 and 8 %).Conclusions: Primary care providers do not consistently follow recent USPSTF breast and cervical cancer screening recommendations, despite noting that these guidelines are influential. [ABSTRACT FROM AUTHOR]

Hidden/special populations such as new immigrants are hard-to-reach due to issues such as stigma, discrimination, fear of immigration authorities, and cultural norms. Such factors can affect the recruitment of participants for behavioral research, especially research which addresses stigmatizing conditions such as HIV/AIDS. This research involved a qualitative approach and methods. The study identified contextual factors as well as attitudes, experiences and beliefs affecting HIV risk among recent Hispanic immigrants in New York. During the course of this research, challenges to participant recruitment were identified which were related to the environments, characteristics of the populations, and the sensitive nature of the topic to be studied. Strategies including exploratory fieldwork and sensitivity to participants' fear of 'the system' were effective in recruiting individuals from this population. The authors discuss the strategies which facilitated recruitment of research subjects from these new Hispanic immigrant communities and the importance of behavioral research among these vulnerable communities. [ABSTRACT FROM AUTHOR]

To describe trajectories of aggressive behaviors for adolescents living in rural areas, we compared the patterns, timing and sex differences in development of physical and social aggression using five waves of data collected from youth in school surveys administered over 2.5 years. The sample (N = 5,151) was 50.0% female, 52.1% Caucasian and 38.2% African-American. Multilevel growth curve models showed that physical and social aggression followed curvilinear trajectories from ages 11 to 18, with increases in each type of aggression followed by subsequent declines. Physical aggression peaked around age 15; social aggression peaked around age 14. Boys consistently perpetrated more physical aggression than girls, but the trajectories were parallel. There were no sex differences in the perpetration of social aggression. Given the characteristics of the developmental trajectories observed, interventions with both boys and girls targeting physically and socially aggressive behaviors are needed in early adolescence to slow the development of aggression. [ABSTRACT FROM AUTHOR]

Background: Language barriers in medical care are a large and growing problem in the United States. Most research has focused on how language barriers affect patients. Less is known of the physician perspective and the efforts they are making to overcome these barriers.Objective: To learn about current approaches to communicating with limited English-proficient (LEP) patients and the associated financial and nonfinancial constraints that private practice physicians and managers perceive in providing these services.Design: Computer-assisted telephone focus groups with open-ended discussion guide.Setting: Small private practices in geographic areas that have experienced recent dramatic increases in LEP populations.Participants: Primary care physicians, specialists, and practice managers.Approach: Focus group transcripts were systematically coded using grounded theory analysis. The research team then identified common themes that arose across the groups.Results: Citing the cost, inaccessibility, and inconvenience of using professional interpreters, physicians commonly used family and friends as interpreters. Few recalled any actual experience with professional interpreters or were well-informed about the cost of their services. Physicians and office managers voiced uniform concern about how language barriers impede quality and safety of patient care and increased malpractice risk.Conclusions: Health care providers in private practice recognize the importance of overcoming language barriers. However, perceived barriers to implementing cost-effective strategies to these barriers are high. Physicians in private practice would benefit from information about how to best overcome language barriers in their practices efficiently and affordably. [ABSTRACT FROM AUTHOR]

The study objective was to examine quality oversight efforts by Medicaid managed care organizations (MCOs) for children in a sample of ambulatory care institutions and private practices in New York City. This was a cross-sectional study of quality assurance priorities and strategies of MCOs and their impact date in institutions in New York City. Data were from structured interviews administered in 1997 to medical directors in the eight largest MCOs; and medical directors, heads of ambulatory pediatrics, and institutional pediatricians in a random sample of 15 institutions and 20 private office-based providers. Medical directors in MCOs reported that their main priority areas were the preventive care measures (e.g., immunization and lead screening) that they must report to the state. Knowledge of these MCO priority areas and monitoring activities was high for medical directors in the random sample, but decreased from these medical directors to heads of ambulatory pediatrics to institutional pediatricians, with the differences between the medical directors and institutional pediatricians significant (P < .05). However, 96% of the institutional pediatricians reported knowing their own institution's priorities and monitoring activities. In contrast, most private pediatricians reported they knew MCO priorities and monitoring activities (80%). Less than 33% of any group reported activities as "very effective" or felt any incentive to improve performance. There was a high level of overlap in provider networks, with institutions and private providers having children in many MCOs, and MCOs having children in many sites. Conclusions. The current model of quality oversight is producing reports for the state, but is not translating into effective strategies at the provider level. The need to work through the leadership in institutions to influence quality is highlighted. The level of overlap in provider networks suggests the need for collaboration among MCOs in quality monitoring. [ABSTRACT FROM AUTHOR]

Data from the 1987-1988 National Survey of Families and Households are used to provide national estimates of cohabitation trends and levels. The rapid increase since around 1970 is documented over both birth cohorts and marriage cohorts. Almost half of the persons in their early 30s and half of the recently married have cohabited. Changes in the proportion ever married are compared with changes in the proportion who have either married or cohabited. Much of the decline in marriage has been offset by increased living together without being married. The stability of unions of various types is compared. Cohabitations end very quickly in either marriage or disruption. About 60 percent of all first cohabitations result in marriage. Cohabiting unions and marriages preceded by cohabitation are much more likely to break up than are unions initiated by marriage. Multivariate analysis reveals higher rates of cohabitation among women, whites, persons who did not complete high school, and those from families who received welfare or who lived in a single-parent family while growing up. [ABSTRACT FROM AUTHOR]

Data from the National Longitudinal Study of the High School Class of 1972 are used to examine factors influencing young adults' departure from the parental home and the initial pathways taken, including leaving home for marriage, residential semi-autonomy (Semi), and premarital residential independence (PRI). Parents' education and continuing in school decrease the likelihood of leaving home via marriage and increase the likelihood of leaving home via Semi or PRI. All other factors considered affect all pathways out of the parental home in the same direction, but in differing magnitudes. The predominant influences on PRI are indicators of modern family values, whereas the predominant influences on leaving home for marriage are measures of resources, both those of the parents and those of the young adults. [ABSTRACT FROM AUTHOR]

Contrary to observed trends in religious fertility and contraceptive use differentials, Catholic/non-Catholic differentials in attitudes toward abortion have not been converging. This study suggests that this may be due to an interaction between religiosity and education. In a sample of Catholic Mexican-American women in Los Angeles County, the authors found that among respondents brought up in Mexico, education had a liberalizing effect on their attitudes. With the exception of the most devout, the same trend was observed among U.S.-reared respondents. Among the most religious group, however, education had the opposite effect, suggesting that convergence will be delayed. [ABSTRACT FROM AUTHOR]

A theoretical and analytic model of fertility intentions is proposed which treats "don't know" responses and other uncertain responses as distinct from more firm intentions. Methodologically, these analyses show that "don't know" responses need not be treated as missing data, but instead are both valid and meaningful responses. Furthermore, eliminating these uncertain respondents would have the negative effects of distorting across survey comparisons in intentions due to shifts in aggregate uncertainty, reducing the likelihood of accurately detecting shifts in fertility intentions, and lessening the representatives of the sample analyzed. Substantively, in conjunction with Morgan (1981), these results show that the sharp 1965-76 decline in the likelihood of intending more births at parities 2 through 5 occurred as women halted childbearing at minimal acceptable levels and postponed further childbearing. With time (or age), this delayed fertility became fertility about which the respondent was uncertain and, finally, fertility foregone. Since 1970, similar shifts are observed at parities 0 and 1, perhaps foreshadowing an increase in voluntary childlessness and one-child families. [ABSTRACT FROM AUTHOR]