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The effect of language acculturation, socioeconomic status (SES), and immigrant generation on development of diabetes among Mexican Americans was evaluated in the Hispanic Established Population for the Epidemiologic Study of the Elderly (HEPESE). HEPESE is a longitudinal cohort study of 3,050 non-institutionalized Mexican Americans aged 65 years at baseline (1993-1994) from 5 Southwestern states. Diabetes incidence was ascertained in 4 follow-up surveys to 2004-05 by respondent self-reported physician-diagnosis of diabetes, high blood glucose, or sugar in the urine. Language of interview, immigrant generation, gender, age, education, family history of diabetes, smoking status, alcohol use, health insurance type and self-reported height and weight were assessed. High socioeconomic status (SES) was defined by high school graduation and non-Medicaid insurance. Cox's proportional hazards models were fit to evaluate the effects of language acculturation, generation and SES on incident diabetes. 845 of 3,050 (27.7%) Mexican Americans had diabetes at baseline and were younger, more educated, and more likely to have health insurance than those without diabetes. Risk of developing diabetes increased for Spanish-speaking respondents with low SES from 1st to 3rd generation (HR = 1.76, 95% CI = 1.02-3.03) and from 2nd to 3rd generation (HR = 2.15, 95% CI = 1.20-3.84). Among English-speaking, high SES participants, generation had a protective effect on developing diabetes: HR = 0.45 (95% CI = 0.22-0.91) when comparing 3rd versus 1st generation. The effect of language acculturation and immigrant generation on incident diabetes is moderated by SES status in HEPESE participants.

BACKGROUND:: Adjustment for differing risks among patients is usually incorporated into newer payment approaches, and current risk models rely on age, sex, and diagnosis codes. It is unknown the extent to which controlling additionally for disease severity improves cost prediction. Failure to adjust for within-disease variation may create incentives to avoid sicker patients. We address this issue among patients with chronic obstructive pulmonary disease (COPD). METHODS:: Cost and clinical data were collected prospectively from 1202 COPD patients at Kaiser Permanente. Baseline analysis included age, sex, and diagnosis codes (using the Diagnostic Cost Group Relative Risk Score) in a general linear model predicting total medical costs in the following year. We determined whether adding COPD severity measures - forced expiratory volume in 1 second, 6-Minute Walk Test, dyspnea score, body mass index, and BODE Index (composite of the other 4 measures) - improved predictions. Separately, we examined household income as a cost predictor. RESULTS:: Mean costs were $12,334/y. Controlling for Relative Risk Score, each 1/2 SD worsening in COPD severity factor was associated with $629 to $1135 in increased annual costs (all P

Although risk for cardiovascular disease (CVD) increases during the menopausal transition,1–12 the disease processes underlying the emergence of CVD during this period may begin pre-menopausally as is suggested by studies documenting fatty streaks as well as clinically significant atherosclerotic lesions in young, pre-menopausal women and adolescent girls.13–16 To date, however, factors contributing to atherosclerotic disease development pre-menopausally that may explain variability in CVD post-menopausally are poorly understood. In this context, Kaplan and Manuck have proposed the “precocious acceleration” hypothesis, suggesting that disruptions in ovarian function during the pre-menopausal period (even when mild) can promote atherosclerosis, leading to an accelerated course of disease and increased post-menopausal risk for CVD.17–18 This hypothesis is supported by studies in which women with apparent impairments in ovarian function, marked by anovulation, lower estrogen, and menstrual cycle irregularity, exhibited increased risk for CVD or more problematic CVD risk factor profiles.19–25 Poorer psychological health has been associated with disruptions in ovarian function indexed by menstrual cycle characteristics. Findings drawn from three, largely separate literatures show that i) women with psychiatric disorders frequently experience menstrual cycle abnormalities including increased irregularity and patterns of both shorter and longer cycle length26–29; ii) psychological stress, especially when extreme, can play an etiological role in the cessation of menses30–33; and iii) risk for depressive symptoms increases during peri-menopause, a time when menstrual cycles become less regular due to reproductive aging.34 Poorer psychological health has also been associated with risk for CVD. In particular, depression, including major and minor depressive disorder as well as depressive symptomatology, has been shown to predict incident myocardial infarction, cardiac-specific, and all-cause mortality.35–40 With respect to the examination of cardiovascular risk factors, depression, especially among women, confers risk for the development of metabolic syndrome41–43 and negative psychological factors more broadly are correlated (although not always41–42) with the individual components of metabolic syndrome (i.e., high-density lipoprotein [HDL], triglycerides, waist circumference, glucose, and blood pressure).43–45 To integrate and extend the existing literature, the primary goal of the current study was to evaluate whether mild disruptions in ovarian function among healthy, regularly-cycling women are related to markers of cardio-metabolic health as well as depression. Given the inter-relations between disruptions in ovarian function, cardio-metabolic risk factors, and depression, secondarily, we also explored a model in which disruptions in ovarian function were proposed to play a mediating role (at least partially) in linking depression and cardio-metabolic risk. The study objectives were pursued in a multi-ethnic sample of 804 healthy, regularly-cycling pre-menopausal women in whom we examined disruptions in ovarian function as marked by having experienced any change (i.e., shortening, lengthening, or becoming more variable) compared to no change in menstrual cycle length in relation to standard cardio-metabolic risk factors and in relation to current depressive symptomatology and depression history.

Objectives Typical measures of childhood socioeconomic status (SES), such as father9s occupation, have limited the ability to elucidate mechanisms by which childhood SES affects adult health. Mechanisms could include schooling experiences or work opportunities. Having previously used qualitative methods for concept development, we developed new retrospective measures of multiple domains of childhood social and economic circumstances in ethnically diverse older adults. We administered the new measures in a large sample and explored their association with adult SES. Design We used a cross-sectional survey design with a community sample. Setting The San Francisco Bay Area in California. Participants 400 community-dwelling adults from diverse racial/ethnic backgrounds (Whites, African Americans, Latinos and Asians/Pacific Islanders) aged 55 and older (mean=67 years); 61% were women. Primary and secondary outcome measures We measured attitudes towards schooling, extracurricular activities and adult encouragement and discouragement during the childhood/teen years. Bivariate analysis tested racial/ethnic differences on the various measures. Multivariate regression models estimated the extent to which retrospective circumstances were independently associated with adult educational attainment and adult health. Results Most of the childhood circumstances measures differed across racial/ethnic groups. In general, Whites reported more positive circumstances than non-Whites. Family financial circumstances, respondent9s perception of schooling as a means to get ahead, high school extracurricular activities, summer travel and summer reading were each statistically significantly associated with adult SES. Family composition, age began work, high school extracurricular activities, attitudes towards schooling and adult discouragement were associated with adult health.

HIV+ inmates reentering their communities are at increased risk for poor health outcomes and for transmitting HIV. This article reports on a randomized trial comparing an ecosystem-based intervention and an individually focused intervention for reducing HIV transmission risk and improving medication adherence. Reincarceration was considered as a secondary variable. Both groups decreased sexual risk behavior over the 12-month follow-up period. Unexpectedly, the ecosystem intervention group was less likely to be taking medication or to be adherent and more likely to have been reincarcerated. Failure to demonstrate a significant advantage of the ecosystem intervention may have resulted from the difficulty of engaging family and other ecosystem members in the intervention. Implications for developing and applying interventions for this population are discussed.

ObjectiveTo determine whether greater childhood adversity relates to younger menarcheal age; whether younger menarcheal age relates to increased CVD risk; and whether greater childhood adversity relates to increased CVD risk, directly or indirectly (mediated by menarcheal age).MethodsAmong 650 pre-menopausal women (ages 25-45; M=34.9[5.6]), SEM was performed to estimate relations between childhood adversity, menarcheal age, and CVD risk.ResultsResults supported a covariate-adjusted model (RMSEA=0.035; CFI=0.983) in which greater childhood adversity was related to younger menarcheal age (β=-.13, p

ObjectivesAlthough oral health (OH) problems are common during pregnancy, little is known about individual characteristics or behaviors relating to clinically assessed OH during pregnancy. This cross-sectional study describes the clinical OH status of a sample of pregnant women, examines relationships between sociodemographic factors and OH, behavioral factors and OH, and the influence of behavior on the relationships between sociodemographic clusters and OH. Baseline data were utilized from a pilot intervention study promoting OH during pregnancy.MethodsParticipants (n=99), recruited from CenteringPregnancy(®) prenatal care groups completed questionnaires addressing race/ethnicity, income, education, dental insurance, oral hygiene practices, and dental care utilization; and clinical examinations for periodontal probing depths (PD), bleeding on probing (BOP), plaque assessment, and visual detection of untreated decay. Chi-squares and one-way anovas with Tukey's studentized range test of planned comparisons were conducted to examine bivariable relationships between both sociodemographic and behavioral characteristics to OH status. Multivariable logistic regression analyses tested whether the effects of sociodemographic variables on OH status might be mediated by behaviors, including self-reported oral hygiene and recent dental visits.ResultsForty-five percent of the sample had untreated decay and the mean percentage of sites with BOP=18%. Bivariable analyses of sociodemographic factors indicated that compared with Whites, Hispanic women had greater % of sites with: BOP, PD ≥5mm plus BOP, and Plaque Index (PI) scores of ≥2, all P=0.05; and greater untreated decay (Chi-square 13.3, P&nbsp

Recent models of depression have proposed that major depressive disorder (MDD) may accelerate biological aging,1–2 citing associations between depression and markers of cellular aging.3–6 Whether depression may be linked to aspects of reproductive biology underlying ovarian aging in particular, however, is not known. At present, epidemiological support for a connection between depression and ovarian aging stems primarily from The Harvard Study of Moods and Cycles in which women with a history of MDD compared to women with no current or prior history of MDD experienced a 20% increased rate of entry into peri-menopause, independently of confounding factors (e.g., cigarette smoking).7 In addition, women with more severe depressive symptomatology (assessed by a score of 8+ on the Hamilton Rating Scale for Depression) and women with more severe depressive symptomatology who were also taking anti-depressant medications had 2 and 3 times, respectively, the risk of entering peri-menopause earlier than their never-depressed counterparts. An abundant literature shows depression and psychological stress are strongly interrelated. In vulnerable individuals, psychosocial stressors can trigger the onset of depression and once depression has developed, influence its severity, course, and probability of recurrence.8–13 Moreover, being depressed may itself increase one’s sensitivity to stress making the ill effects of subsequent (even minor) stressors more potent.14–15 It has been hypothesized that the connection between stress and depression may partially explain the 2-fold increased risk of depression in women compared to men.16 Women are disproportionately exposed to stress and/or respond to stress more intensely17–18; women report higher levels of perceived stress19; and women are more likely to have experienced significant life stress prior to the onset of depression.20 The commonness of experiencing psychological stress highlights the importance of understanding its putative role in promoting and exacerbating depression outcomes as well as depression-related sequelae such as potential biological alterations underlying mechanisms of somatic aging. To date, most investigations of depression and ovarian function have examined reproductive hormones as indicators of ovarian age (e.g.,21–23). Because such markers (e.g., follicular-phase levels of FSH) are widely variable in aging and do not appreciably change until a woman has already experienced a significant loss in ovarian function,24–25 their use remains limited. Alternatively, advances in transvaginal ultrasonography (TVUS) in infertile women have recently been applied in healthy women to evaluate antral follicle count (AFC), an indirect measure of the number of primordial follicles remaining in the ovary.26–28 Validity for the use of AFC as a marker of ovarian reserve is supported by studies showing AFC to covary with chronological age, correlate with ovarian response in treatments using Assisted Reproductive Technologies (ARTs), and, in statistical models, predict menopause onset.27,29–37 In contrast to hormonal indicators, AFC is stable across consecutive menstrual cycles and across follicular and luteal phases of the menstrual cycle.33,38–39 Taken together, evidence supports the value of utilizing AFC as a tool in studying ovarian follicle loss and the factors that may influence this process. The goals of the current study were to examine depression as well as depression in combination with psychological stress in relation to ovarian aging in a multi-ethnic cross-sectional sample of 683 pre-menopausal women. In accordance with the present literature, we sought to determine whether 1) AFC decline across women would be greater among women reporting higher levels of depression; and 2) whether there would be an exacerbating effect of stress whereby AFC decline across women would be greater among women reporting higher levels depression and higher levels psychological stress. These hypotheses were tested via 2-(age-x-depression) and 3-way (age-x-depression-x-stress) interactions in relation to AFC. On an a priori basis, depression levels were evaluated by the total score of the Center for Epidemiological Studies Depression Scale (CESD) as well as its subscale scores which represent particular types of depressive symptoms (e.g., depressed affect); psychological stress was measured by the Perceived Stress Scale. All analyses included statistical adjustment for possible confounding factors (i.e., race/ethnicity, SES, menarcheal age, use of hormone-containing medication for birth control, parity, cigarette smoking, and BMI). For conceptual clarity, throughout the current report we use the term decline to describe AFC differences across women to reflect the age-related phenomenon that the number of ovarian antral follicles decreases with advancing chronological age; however, we emphasize that the current study is cross-sectional and these differences are reported across and not within individuals.

Objective. Evaluate effect of gender role attitudes on tobacco and alcohol use among Argentinean girls. Method. Cross-sectional survey of 10th grade students attending 27 randomly selected schools in Jujuy, Argentina. Questions about tobacco and alcohol use were adapted from global youth surveys. Five items with 5-point response options of agreement–disagreement assessed attitude towards egalitarian (higher score) gender roles. Results. 2133 girls, aged 13–18 years, 71% Indigenous, 22% mixed Indigenous/European, and 7% European responded. Of these, 60% had ever smoked, 32% were current smokers, 58% ever drinkers, 27% drank in previous month, and 13% had ≥5 drinks on one occasion. Mean response to the gender role scale was 3.49 (95% Confidence Intervals = 3.41–3.57) out of 5 tending toward egalitarian attitudes. Logistic regression models using the gender role scale score as the main predictor and adjusting for demographic and social confounders showed that egalitarian gender role was associated with ever smoking (Odds Ratio = 1.25; 95% Confidence Intervals 1.09–1.44), ever drinking (Odds Ratio =1.24; 95% Confidence Intervals 1.10–1.40), drinking in prior month (Odds Ratio = 1.21; 95% Confidence Intervals 1.07–1.37) and ≥5 drinks on one occasion (Odds Ratio = 1.15; 95% Confidence Intervals 1.00–1.33), but was not significant for current smoking. Conclusion. Girls in Jujuy who reported more egalitarian gender role attitudes had higher odds of smoking or drinking. Fil: Mejia, Raul Mariano. Universidad de Buenos Aires; Argentina. Centro de Estudios de Estado y Sociedad; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Kaplan, Celia. University of California San Francisco. Department of Medicine. Medical Effectiveness Research Center for Diverse Populations. Division of General Internal Medicine; Estados Unidos Fil: Alderete, Ethel del Carmen. Instituto de Ciencia y Tecnologia Regional; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Gregorich, Steven E.. University of California San Francisco. Department of Medicine. Medical Effectiveness Research Center for Diverse Populations. Division of General Internal Medicine; Estados Unidos Fil: Pérez Stable, Eliseo J.. Centro de Estudios de Estado y Sociedad; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. University of California San Francisco. Department of Medicine. Medical Effectiveness Research Center for Diverse Populations. Division of General Internal Medicine; Estados Unidos

Objectives. We evaluated a community-based, translational lifestyle program to reduce diabetes risk in lower–socioeconomic status (SES) and ethnic minority adults. Methods. Through an academic–public health department partnership, community-dwelling adults at risk for diabetes were randomly assigned to individualized lifestyle counseling delivered primarily via telephone by health department counselors or a wait-list control group. Primary outcomes (6 and 12 months) were fasting glucose level, triglycerides, high- and low-density lipoprotein cholesterol, weight, waist circumference, and systolic blood pressure. Secondary outcomes included diet, physical activity, and health-related quality of life. Results. Of the 230 participants, study retention was 92%. The 6-month group differences for weight and triglycerides were significant. The intervention group lost 2 pounds more than did the control group (P = .03) and had decreased triglyceride levels (difference in change, 23 mg/dL; P = .02). At 6 months, the intervention group consumed 7.7 fewer grams per day of fat (P = .05) and more fruits and vegetables (P = .02) than did control participants. Conclusions. Despite challenges designing effective translational interventions for lower-SES and minority communities, this program modestly improved some diabetes risk factors. Thus, individualized, telephone-based models may be a promising alternative to group-based interventions.

background: Life history models suggest that biological preparation for current versus longer term reproduction is favored in environments of adversity. In this context, we present a model of reproductive aging in which environmental adversity is proposed to increase the number of growing follicles at the cost of hastening the depletion of the ovarian reserve over time. We evaluated this model by examining psychological stress in relation to reproductive aging indexed by antral follicle count (AFC), a marker of total ovarian reserve. We hypothesized that stress would be related to (i) higher AFC in younger women, reflecting greater reproductive readiness as well as (ii) greater AFC loss across women, reflecting more accelerated reproductive aging. methods: In a multi-ethnic, community sample of 979 participants [ages 25–45 (mean (standard deviation) ¼ 35.2 (5.5)); 27.5% Caucasian] in the Ovarian Aging study, an investigation of the correlates of reproductive aging, the interaction of age-x-stress was assessed in relation to AFC to determine whether AFC and AFC loss varied across women experiencing differing levels of stress. Stress was assessed by the perceived stress scale and AFC was assessed by summing the total number of antral follicles visible by transvaginal ultrasound. results: In linear regression examining AFC as the dependent variable, covariates (race/ethnicity, socio-economic status, menarcheal age, hormone-containing medication for birth control, parity, cigarette smoking, body mass index, waist-to-hip ratio) and age were entered on step 1, stress on step 2 and the interaction term (age-x-stress) on step 3. On step 3, significant main effects showed that older age was related to lower AFC (b ¼ 20.882, P ¼ 0.000) and greater stress was related to higher AFC (b ¼ 0.545, P ¼ 0.005). Follow-up analyses showed that the main effect of stress on AFC was present in the younger women only. A significant interaction term (b ¼ 20.036, P ¼ 0.031) showed the relationship between age and AFC varied as function of stress. When the sample was divided into tertiles of stress, the average follicle loss was 20.781, 20.842 and 20.994 follicles/year in the low-, mid- and high-stress groups, respectively. conclusions: Psychological stress was related to higher AFC among younger women and greater AFC decline across women, suggesting that greater stress may enhance reproductive readiness in the short term at the cost of accelerating reproductive aging in the long term. Findings are preliminary, however, due to the cross-sectional nature of the current study.

To evaluate the prospective relation between dispositional traits of optimism and pessimism and in vitro fertilization (IVF) treatment failure among women seeking medical intervention for infertility.Among 198 women (aged 24-45 years, mean [standard deviation] = 35.1 [4.1] years; white, 77%), the outcome of each participant's first IVF treatment cycle was examined. Treatment outcome was classified as being successful (versus failed) if the woman either delivered a baby or was pregnant because of the cycle by the end of the 18-month study period. At baseline, optimism and pessimism were measured as a single bipolar dimension and as separate unipolar dimensions according to the Life Orientation Test total score and the optimism and pessimism subscale scores, respectively.Optimism/pessimism, measured as a single bipolar dimension, predicted IVF treatment failure initially (B = -0.09, p = .02, odds ratio [OR] = 0.917, 95% confidence interval [CI] = 0.851-0.988), but this association attenuated after statistical control for trait negative affect (B = -0.06, p = .13, OR = 0.938, 95% CI = 0.863-1.020). When examined as separate unipolar dimensions, pessimism (B = 0.14, p = .04, OR = 1.146, 95% CI = 1.008-1.303), not optimism (B = -0.09, p = .12, OR = 0.912, 95% CI = 0.813-1.023), predicted IVF treatment failure independently of risk factors for poor IVF treatment response and trait negative affect.Being pessimistic may be a risk factor for IVF treatment failure. Future research should attempt to delineate the biological and behavioral mechanisms by which pessimism may negatively affect treatment outcomes.

Latin America has the highest prevalence of tobacco use by youth. Higher media literacy, defined as the ability to analyze and evaluate media messages, has been associated with lower smoking among youth in the United States. The objective of this study was to determine whether media literacy related to smoking is independently associated with current smoking and susceptibility to future smoking in a sample of mostly indigenous youth in Jujuy, Argentina.In 2006, a self-administered survey was conducted among 10th grade students sampled from 27 randomly selected urban and rural schools in Jujuy. Survey items measured smoking behavior (ever, never, and current), susceptibility to future smoking among never-smokers (definitely not accept a cigarette from a friend or to smoke in the future), 5 items assessing smoking media literacy (SML), and risk factors for smoking.Of the 3,470 respondents, 1,170 (34%) reported having smoked in the previous 30 days (current). Of the 1,430 students who had never smoked, 912 (64%) were susceptible to future smoking. High media literacy was present in 38%. Using multiple logistic regression, fully adjusted models showed that high media literacy was significantly associated as a protective factor of being a current smoker (odds ratio [OR] = 0.81; 95% CI = 0.67-0.97) and of being susceptible to future smoking (OR = 0.73; 95% CI = 0.58-0.92) among those who had never smoked.Among youth in Jujuy, higher SML was significantly associated with both lower current smoking and susceptibility to future smoking. Teaching SML may be a valuable component in a prevention intervention in this population.

This study evaluated how well women from diverse race/ethnic groups were able to take a quantitative cancer risk statistic verbally provided to them and report it in a visual format.Cross-sectional survey was administered in English, Spanish or Chinese, to women aged 50-80 (n=1160), recruited from primary care practices. The survey contained breast, colorectal or cervical cancer questions regarding screening and prevention. Women were told cancer-specific lifetime risk then shown a visual display of risk and asked to indicate the specific lifetime risk. Correct indication of risk was the main outcome.Correct responses on icon arrays were 46% for breast, 55% for colon, and 44% for cervical; only 25% correctly responded to a magnifying glass graphic. Compared to Whites, African American and Latina women were significantly less likely to use the icon arrays correctly. Higher education and higher numeracy were associated with correct responses. Lower education was associated with lower numeracy.Race/ethnic differences were associated with women's ability to take a quantitative cancer risk statistic verbally provided to them and report it in a visual format.Systematically considering the complexity of intersecting factors such as race/ethnicity, educational level, poverty, and numeracy in most health communications is needed.

Objective Identifying persons with systemic lupus erythematosus (SLE) at risk for depression would facilitate the identification and treatment of an important comorbidity conferring additional risk for poor outcomes. The purpose of this study was to determine the utility of a brief screening measure, the Center for Epidemiologic Studies Depression Scale (CES-D), in detecting mood disorders in persons with SLE. Methods This cross-sectional study examined 150 persons with SLE. Screening cut points were empirically derived using threshold selection methods, and receiver operating characteristic curves were estimated. The empirically derived cut points of the CES-D were used as the screening measures and were compared to other commonly used CES-D cut points in addition to other commonly used methods to screen for depression. Diagnoses of major depressive disorder or other mood disorders were determined using a “gold standard” structured clinical interview. Results Of the 150 persons with SLE, 26% of subjects met criteria for any mood disorder and 17% met criteria for major depressive disorder. Optimal threshold estimations suggested a CES-D cut score of 24 and above, which yielded adequate sensitivity and specificity in detecting major depressive disorder (88% and 93%, respectively) and correctly classified 92% of participants. To detect the presence of any mood disorder, a cut score of 20 and above was suggested, yielding sensitivity and specificity of 87% and correctly classifying 87%. Conclusion These results suggest the CES-D may be a useful screening measure to identify patients at risk for depression.

Patient-reported measures of clinicians' cultural sensitivity are important to assess comprehensively quality of care among ethnically diverse patients and may help address persistent health inequities.Create a patient-reported, multidimensional survey of clinicians' cultural sensitivity to cultural factors affecting quality of care.Using a comprehensive conceptual framework, items were written and field-tested in a cross-sectional telephone survey. Multitrait scaling and factor analyses were used to develop measures.Latino patients age ≥50 from primary care practices in California.Thirty-five items hypothesized to assess clinicians' sensitivity.Validity and reliability of cultural sensitivity measures.Twenty-nine of 35 items measuring 14 constructs were retained. Eleven measures assessed sensitivity issues relevant to all participants: complementary and alternative medicine, mind-body connections, causal attributions, preventive care, family involvement, modesty, prescription medications, spirituality, physician discrimination due to education, physician discrimination due to race/ethnicity and staff discrimination due to race/ethnicity. Three measures were group specific: two to limited English proficient patients (sensitivity to language needs and discrimination due to language) and one to immigrants (sensitivity to immigrant status). Twelve multi-item scales demonstrated adequate reliability (alpha ≥0.68 except for Spanish discrimination due to education) and evidence of construct validity (item-scale correlations for all scales0.40 except for sensitivity to immigrant status). Two single-item measures demonstrated sufficient construct validity to retain for further development.The Clinicians' Cultural Sensitivity Survey can be used to assess the quality of care of older Latino patients.

The purpose of this study was to determine whether age at first uterus-preserving treatment (UPT) predicts symptom resolution among women with common pelvic problems.We conducted an analysis of 557 participants in the Study of Pelvic Problems, Hysterectomy and Intervention Alternatives cohort who reported having undergone a UPT. We performed multivariable regression modeling age at first UPT, hysterectomy, menopause, and other covariates to predict symptom resolution.Mean ± SD age at enrollment was 42.7 ± 4.7 years; mean follow-up time was 4.4 ± 2.7 years. Sixteen percent of the women underwent hysterectomy; 37% of the women entered menopause. Hysterectomy was a strong predictor of symptom resolution (P.001). Compared with women who were younger (first UPT at age40 years), older women reported greater symptom resolution, even after the data were controlled for hysterectomy use and menopausal status (P = .028).Women who are ≥40 years old when they undergo their first uterus-preserving treatment experience greater symptom resolution than younger women. Framing UPTs as hysterectomy alternatives may be accurate only for a subset of women who are40 years old.

The purpose of this study was to determine whether depression influences treatment outcomes and to identify predictors of symptom resolution among women with chronic pelvic pain (CPP).Analysis of 701 women with CPP in the Study of Pelvic Problems, Hysterectomy and Intervention Alternatives prospective cohort study, which included 153 women (22%) with depression. We conducted multivariable analyses to evaluate the influence of depression on pre-/posttreatment differences in symptoms and health-related quality of life and to identify other predictors of symptom improvement.CPP treatments included hysterectomy (9%), other surgical treatments (9%), hormonal medications (50%), narcotic analgesics (47%), physical therapy (12%), and nonprescription medications (93%). Depression predicted lower gains in health perception (P.05) but not in symptom resolution, sexual functioning, or other aspects of health-related quality of life. Symptom resolution was predicted by hysterectomy (P.001), entering menopause (P.001), and pretreatment satisfaction with sex (P = .039).Depression does not influence substantially treatment-related gains in CPP symptom resolution and health-related quality of life. Coexisting depression should not delay treatment for CPP.

Background Neighborhood environments affect children's health outcomes. Observational methods used to assess neighborhoods can be categorized as indirect, intermediate, or direct. Direct methods, involving in-person audits of the neighborhoods conducted by trained observers, are recognized as an accurate representation of current neighborhood conditions. The authors investigated the associations of various neighborhood characteristics with young girls' diet and physical activity. Methods This study is based on a subset of participants in the Cohort Study of Young Girls' Nutrition, Environment and Transitions (CYGNET). In-person street audits were conducted within 215 girls' residential neighborhoods using a modified St. Louis Audit Tool. From the street audit data, exploratory factor analysis revealed five neighborhood scales: "mixed residential and commercial," "food and retail," "recreation," "walkability," and "physical disorder." A Neighborhood Deprivation Index was also derived from census data. The authors investigated if the five neighborhood scales and the Neighborhood Deprivation Index were associated with quartiles of total energy intake and expenditure (metabolic equivalent (MET) hours/week) at baseline, and whether any of these associations were modified by race/ethnicity. Results After adjustment for demographic characteristics, there was an inverse association between prevalence of "food and retail" destinations and total energy intake (for a one quartile increase, OR = 0.84, 95% CI 0.74, 0.96). Positive associations were also observed between the "recreation" and "walkability" scales with physical activity among Hispanic/Latina girls (for a one quartile increase in MET, OR = 1.94, 95% CI 1.31, 2.88 for recreation; OR = 1.71, 95% CI 1.11, 2.63 for walkability). Among African-American girls, there was an inverse association between "physical disorder" and physical activity (OR = 0.31, 95% CI 0.12, 0.80). Conclusions These results suggest that neighborhood food and retail availability may be inversely associated with young girls' energy intakes in contrast to other studies' findings that focused on adults. There is considerable variation in neighborhoods' influences on young girls' physical activity behaviors, particularly for young girls of different racial/ethnic backgrounds.

To examine whether a multidimensional social support instrument can be used for comparative research in four diverse ethnic groups of women (African American, Latina, Chinese, non-Latina White). The social support instrument was administered as part of a larger survey to 1,137 women. We tested the reliability and validity of this instrument. A confirmatory factor analytic (CFA) framework was used to test for the invariance of the instrument's psychometric properties across ethnic groups. We used multitrait scaling to eliminate items that did not meet the item-convergence criterion (r > 0.30) and where items were non-convergent items in at least three groups. A series of nested CFA models assessed the level of factorial invariance. One thousand seventy-four women completed the survey; Their mean age was 61 years with Chinese and Latinas reporting lower education compared to non-Latino Whites (p

To identify static and time-varying sociodemographic, clinical, health-related quality-of-life and attitudinal predictors of use and satisfaction with hysterectomy for noncancerous conditions.The Study of Pelvic Problems, Hysterectomy, and Intervention Alternatives (SOPHIA) was conducted from 1998 to 2008. English-, Spanish-, or Chinese-speaking premenopausal women (n=1,420) with intact uteri who had sought care for pelvic pressure, bleeding, or pain from an academic medical center, county hospital, closed-panel health maintenance organization, or one of several community-based practices in the San Francisco Bay area were interviewed annually for up to 8 years. Primary outcomes were use of and satisfaction with hysterectomy.A total of 207 women (14.6%) underwent hysterectomy. In addition to well-established clinical predictors (entering menopause, symptomatic leiomyomas, prior treatment with gonadotropin-releasing hormone agonist, and less symptom resolution), greater symptom impact on sex (P=.001), higher 12-Item Short Form Health Survey mental component summary scores (P=.010), and higher scores on an attitude measure describing "benefits of not having a uterus" and lower "hysterectomy concerns" scores (P.001 for each) were predictive of hysterectomy use. Most participants who underwent hysterectomy were very (63.9%) or somewhat (21.4%) satisfied in the year after the procedure, and we observed significant variations in posthysterectomy satisfaction across the clinical sites (omnibus P=.036). Other determinants of postsurgical satisfaction included higher pelvic problem impact (P=.035) and "benefits of not having a uterus" scores (P=.008) before surgery and greater posthysterectomy symptom resolution (P=.001).Numerous factors beyond clinical symptoms predict hysterectomy use and satisfaction. Providers should discuss health-related quality of life, sexual function, and attitudes with patients to help identify those who are most likely to benefit from this procedure.

Linguistic interpretation ameliorates health disparities disfavoring underserved limited English-proficient patients, yet few studies have compared clinician satisfaction with these services. Self-administered clinician post-visit surveys compared the quality of interpretation and communication, visit satisfaction, degree of patient engagement, and cultural competence of visits using untrained people acting as interpreters (ad hoc), in-person professional, or video conferencing professional interpretation for 283 visits. Adjusting for clinician and patient characteristics, the quality of interpretation of in-person and video conferencing modes were rated similarly (OR 1.79, 95% CI 0.74, 4.33). The quality of in-person (OR 5.55, 95% CI 1.50, 20.51) and video conferencing (OR 3.10, 95% CI 1.16, 8.31) were rated higher than ad hoc interpretation. Self-assessed cultural competence was better for in-person versus video conferencing interpretation (OR 2.32, 95% CI 1.11, 4.86). Video conferencing interpretation increases access without compromising quality, but cultural nuances may be better addressed by in-person interpreters. Professional interpretation is superior to ad hoc (OR 4.15, 95% CI 1.43, 12.09).

This study examines alternative tobacco use among Latin American youth. A self-administered survey in a random sample of 27 schools was administered in 2004 in Jujuy, Argentina (N = 3218). Prevalence of alternative tobacco product use was 24.1; 15.3 of youth used hand-rolled cigarettes, 7.8 smoked cigars, 2.3 chewed tobacco leaf and 1.6% smoked pipe. Among youth who never smoked manufactured cigarettes, alternative product use was rare (2.9), except for chewing tobacco (22). In multivariate logistic regression boys were more likely than girls to smoke pipe (OR=3.1; 95 CI 1.1-8.7); indigenous language was associated with smoking hand-rolled cigarettes (OR=1.4; 95 CI-1.1-1.9) and pipe (OR=2.2; 95 CI 1.5-3.4). Working in tobacco sales was a risk factor for chewing tobacco (OR=2.9; 95 CI: 1.7-4.9) and smoking hand-rolled cigarettes (OR=1.4; 95 CI 1.1-1.8). Having friends who smoked was associated with chewing tobacco (OR=1.8; 95 CI 1.0-3.2) and with smoking cigars (OR=2.1; 95 CI 1.5-2.9). Current drinking and thrill-seeking orientation were associated with cigars and pipe smoking. Findings highlight the importance of surveillance of alternative tobacco products use and availability among youth and for addressing identified risk factors. Copyright © 2010 Ethel Alderete et al. Fil: Alderete, Ethel del Carmen. Instituto de Ciencia y Tecnología Regional; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Kaplan, Celia Patricia. University of California; Estados Unidos Fil: Gregorich, Steven E.. University of California; Estados Unidos Fil: Pérez Stable, Eliseo J.. University of California; Estados Unidos

Depression and chronic obstructive pulmonary disease (COPD) are major causes of disability. Identifying COPD patients at risk for depression would facilitate the alleviation of an important comorbidity conferring additional risk for poor outcomes. The purpose of this study was to determine the utility of a brief screening measure, the 15-item Geriatric Depression Scale (GDS-15), in detecting the mood disorders in persons with COPD. This is a cross-sectional study of 188 persons with COPD, stratified by age (65 and older versus less than 65) and COPD severity using Global Initiative for Chronic Obstructive Lung Disease (GOLD) staging. Screening cut-points were empirically derived using threshold selection methods and receiver operating characteristic (ROC) curves were estimated. The GDS-15 was used as a screening measure and diagnoses of Major Depressive Disorder (MDD) or other mood disorders were determined using a “gold standard” standardized structured clinical interview. Of the 188 persons with COPD, 25% met criteria for any mood disorder and 11% met criteria for MDD. Optimal threshold estimations suggested a GDS cut score of 5, which yielded adequate sensitivity and specificity in detecting MDD (81% and 87%, respectively) and correctly classified 86% of participants. To detect the presence of any mood disorder, a cut score of 4 was suggested yielding sensitivity and specificity of 67% and 82%, respectively; correctly classifying 79%. These results suggest that mood disorders are relatively common among persons with COPD. The GDS-15 is a useful screening measure to identify patients at risk for depression.

Background Both disability and depression are common in COPD, but limited information is available on the time-ordered relationship between increases in disability and depression onset. Methods Subjects were members of a longitudinal cohort with self-reported physician-diagnosed COPD, emphysema, or chronic bronchitis. Data were collected through three annual structured telephone interviews (T1, T2, and T3). Depression was defined as a score ≥ 4 on the Geriatric Depression Scale Short Form (S-GDS). Disability was measured with the Valued Life Activities (VLA) scale; three disability scores were calculated: percent of VLAs unable to perform, percent of VLAs affected (unable to perform or with some degree of difficulty), and mean VLA difficulty rating. Disability increases were defined as a 0.5 SD increase in disability score between T1 and T2. Multiple logistic regression analyses estimated the risk of T3 depression following a T1 to T2 disability increase for the total cohort and then excluding individuals who met the depression criterion at T1 or T2. Results Approximately 30% of subjects met the depression criterion each year. Eight percent to 19% experienced a T1 to T2 disability increase, depending on the disability measure. Including all cohort members and controlling for baseline S-GDS scores, T1 to T2 increases in disability yielded a significantly elevated risk of T3 depression (% affected odds ratio [OR] =3.6; 95% CI, [1.7, 7.7]; % unable OR = 6.1 [17, 21.8]; mean difficulty OR= 3.6 [1.7, 8.0]). Omitting individuals depressed at T1 or T2 yielded even stronger risk estimates for % unable (OR = 13.4 [2.0, 91.4]) and mean difficulty (OR = 3.9 [1.3, 11.8]). Conclusions Increases in VLA disability are strongly predictive of the onset of depression.

In California, 641 Chinese and 629 Vietnamese age 12–17 participated in a longitudinal telephone study from 1999 to 2001. Four attitude scales were constructed: acceptance of smokers, addictive nature of smoking, psychosocial reasons to smoke, and gender roles and smoking. Vietnamese American adolescents had more pro-smoking attitudes than Chinese American adolescents. Male gender, having friends who smoked, and baseline smoking were associated with smoking susceptibility at follow-up. Those factors, U.S. birthplace, and the acceptance and psychosocial scales were associated with smoking. Smoking prevention efforts targeting Chinese and Vietnamese American adolescents should focus on gender, birthplace, peer smoking, and attitudes.

BACKGROUND:: Research has shown that social networks play an important role in determining health behaviors. However little is known about their influence on male and female condom use among women. METHODS:: We analyzed data obtained from 157 sexually-active women who enrolled in the Female Condom Intervention Trial from June 2003 to November 2004 in Northern California and completed an audio computer-assisted self interview at baseline and 3-months. RESULTS:: At the 3-month assessment the mean number of male and female "conversation" network members (i.e. nonspouse/sex partner people with whom respondents had discussed male and female condoms in the past 3 months) was 1.62 and 1.03 respectively. Results of multiple logistic regression analyses showed that male and female condom use was higher among women with at least 1 network member who encouraged using the male condom (OR 3.39; 95% CI 1.52 7.56) and the female condom (OR 6.03; 95% CI 1.95 18.61) respectively. Female condom use was also associated with having "dense" female condom conversation networks (i.e. at least 2 of respondents network members knew one another; OR 8.42; 95% CI 3.05 23.29). CONCLUSIONS:: The significant association between conversation network characteristics and male and female condom use suggests that more research is needed to better understand the role of conversation networks in affecting condom use among women.

A growing body of evidence supports the link between occupational exposures and COPD. Historically, key evidence to support this association has been industry specific, in particular analyses of dust-years of exposure in coal or gold mining in relation to airflow obstruction.1,2 In more recent years, however, a growing number of investigations has addressed the risk of COPD from work-related exposures across multiple industries and occupations. This approach, frequently defining risk as survey-based reports of exposure to vapors, gas, dust, or fumes (VGDF), has allowed the estimation of risk from a population-based perspective, quantified as the population attributable fraction (PAF). Two systematic reviews of the epidemiological literature have found the PAF for the occupational exposure contribution to the population burden of COPD is approximately 15%.3,4 A recent international ecological analysis of this question indicated that the association between occupational exposure and COPD prevalence is a global phenomenon with an impact on women and men in countries with both more-developed and less-developed economies.5 Risk estimates of occupational exposure have taken into account the concomitant effect of cigarette smoking on population health, which is by far the dominant risk factor for COPD, with an estimated PAF of 80-90%. At the same time, evidence is emerging that the combined effects of occupational exposures and smoking are may be more than additive. In two previous analyses in separate cohorts, we found combined occupational exposure and smoking markedly increased the odds ratios (OR's) for COPD to 18-fold risk compared to non-exposed non-smokers, a modestly supra-additive effect.6,7 Using a recently recruited, community-based cohort of adults with COPD, we re-assessed the relationship between occupational exposure and COPD, including potential combined effects with smoking. We wished to see whether our findings would be consistent with other recent estimates of occupational risk for COPD risk, further supporting a causal interpretation of this association.

Latin America is the world region with the highest rates of youth tobacco use and widest socioeconomic gaps, yet no data are available on smoking among Indigenous people, the largest disadvantaged group in the region. A self-administered survey of 3,131 8th grade youth enrolled in a random sample of 27 urban and rural schools was administered in 2004 in Jujuy, Argentina. Standard questions adapted from global surveys were used. Compared with youth of European background (11.4%; 95% CI 6.7-15.1), Indigenous (23.0%; 95% CI 21.0-25.0), and Mixed ethnicity (23%; 95% CI 18.9-27.1) youth had higher prevalence of current smoking. The odds of current smoking remained significantly elevated for Indigenous (OR 1.9; 95% CI = 1.1-3.3) and Mixed youth (OR 2.0; 95% CI 1.2-3.4) after controlling for confounders. Other risk factors that were associated with current smoking included: having any friends who smoke, repeating a grade in school, depressive symptoms in previous year, drinking any alcohol in the previous week and thrill seeking orientation. These results underscore the importance of social and cultural diversity aspects of the global tobacco epidemic.

Prior research on the risk of depression in chronic obstructive pulmonary disease (COPD) has yielded conflicting results. Furthermore, we have an incomplete understanding of how much depression versus respiratory factors contributes to poor health-related quality of life.Among 1202 adults with COPD and 302 demographically matched referents without COPD, depressive symptoms were assessed using the 15-item Geriatric Depression Score. We measured COPD severity using a multifaceted approach, including spirometry, dyspnea, and exercise capacity. We used the Airway Questionnaire 20 and the Physical Component Summary Score to assess respiratory-specific and overall physical quality of life, respectively.In multivariate analysis adjusting for potential confounders including sociodemographics and all examined comorbidities, COPD subjects were at higher risk for depressive symptoms (Geriatric Depression Scoreor=6) than referents (odds ratio [OR] 3.6; 95% confidence interval [CI], 2.1-6.1; P.001). Stratifying COPD subjects by degree of obstruction on spirometry, all subgroups were at increased risk of depressive symptoms relative to referents (P.001 for all). In multivariate analysis controlling for COPD severity as well as sociodemographics and comorbidities, depressive symptoms were strongly associated with worse respiratory-specific quality of life (OR 3.6; 95% CI, 2.7-4.8; P.001) and worse overall physical quality of life (OR 2.4; 95% CI, 1.8-3.2; P.001).Patients with COPD are at significantly higher risk of having depressive symptoms than referents. Such symptoms are strongly associated with worse respiratory-specific and overall physical health-related quality of life, even after taking COPD severity into account.

The National Institutes of Health define health literacy as the ′′degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.” (1) Patients with inadequate health literacy are more likely to have difficulty understanding written health materials, processing oral communication, and navigating health care environments than those with adequate health literacy. Inadequate health literacy is common, found in one fourth to one third of previously studied populations, and has been linked to poorer health-related knowledge, more health care utilization, and worse outcomes (2–7). There are few studies examining health literacy in patients with end stage kidney disease. Health literacy may be particularly important in the process of qualifying for and receving toward kidney transplantation because that process requires patients to complete several steps. Alexander et al. (8) showed that blacks, the elderly, and the poor were less likely to complete each step in the process toward kidney transplantation. These demographic characteristics have been found to be associated with limited health literacy in several studies (3,4,9). Therefore, variations in health literacy may be an important explanatory factor in linking patient characteristics to disparities in access to kidney transplantation. In addition to having more difficulty in navigating through the transplant process, patients with inadequate health literacy may be less likely to report wanting a transplant because of a lack of understanding of what transplantation entails. Furthermore, nephrologists may be less willing to refer, and transplant centers less willing to wait-list, patients with inadequate health literacy because of perceived patient inability to follow through with prescribed regimens necessary for transplanted graft survival. We hypothesized that inadequate health literacy in a hemodialysis population is common and is associated with poorer access to kidney transplant wait-list.

Subjects were presented with an easy or moderately difficult memorization task and told they could earn either a very low or very high chance of obtaining a modest prize if they did well. A measure of goal attractiveness was taken during an interval immediately preceding the task performance period. As expected, anticipatory goal attractiveness ratings were higher in the moderately difficult condition than in the easy condition when the probability of goal attainment (given success) was high, but were low in both task conditions when the probability of goal attainment (given success) was low. Results are discussed in terms of Brehm's recent theory of motivation.

The performance of pilots can be construed as a product of skill, attitude, and personality factors. Although a great deal of effort within the aviation community has been focused on ensuring technical expertise, and new efforts highlight attitudes associated with crew coordination, personality factors have been relatively unexplored. Further, it is argued that past failures to find linkages between personality and performance were due to a combination of inadequate statistical modeling, premature performance evaluation, and/or the reliance on data gathered in contrived as opposed to realistic situations. The goal of the research presented in this article is to isolate subgroups of pilots along performance-related personality dimensions and to document limits on the impact of crew coordination training between the groups. Two samples of military pilots were surveyed in the context of training in crew coordination. Three different profiles were identified through cluster analysis of personality scales. These clusters replicated across samples and predicted attitude change following training in crew coordination.

Paul D Blanc1,2,3, Mark D Eisner1,2, Edward H Yelin4,5, Gillian Earnest1, John R Balmes1,2, Steven E Gregorich6, Patricia P Katz4,51Division of Occupational and Environmental Medicine, 2Division of Pulmonary and Critical Care Medicine, 4Division of Rheumatology, 6Division of General Internal Medicine, Department of Medicine; 3Cardiovascular Research Institute; 5Institute for Health Policy Studies; University of California San Francisco, San Francisco, CA, USABackground: Inequalities in the use of new medications may contribute to health disparities. We analyzed socioeconomic gradients in the use of tiotropium for chronic obstructive pulmonary disease (COPD).Methods: In a cohort of adults with COPD aged ≥55 years identified through population-based sampling, we elicited questionnaire responses on demographics, socioeconomic status (SES; lower SES defined as high school education or less or annual household income

A revised version of the Cockpit Management Attitudes Questionnaire (CMAQ) is introduced. Factor analyses of responses from 3 different samples reveal comparable factor structure (previous attempts to factor analyze this measure had produced equivocal results). Implications for the measurement of attitudes and the assessment of attitude change are discussed. It is argued that the CMAQ will benefit both special training programs and efforts to explore attitude-performance linkages in air-transport operations.

The diversity of homeless people and the complexity of their problems challenge our understanding of how best to serve them. This article argues that disaffiliation and reaffiliation processes are keys to understanding entrenchment in homelessness and developing remediation strategies. Survey data collected from 166 homeless persons in Austin, Texas, identified four clusters: (1) the Recently Dislocated have small social networks and mild mental health problems; (2) the Vulnerable have been homeless longer, have fewer people in their social networks, and border on severe dysfunction; (3) the Outsiders have been homeless about as long as the Vulnerable but have much larger social networks and function as well as the Recently Dislocated; (4) the Prolonged have been homeless for more than five years, have few people in their networks, and appear moderately dysfunctional. Comparison of life experiences of these four groups provided information on the social processes leading toward entrenchment in homelessness.

Objective. To create a patient-reported, multidimensional physician/patient interpersonal processes of care (IPC) instrument appropriate for patients from diverse racial/ethnic groups that allows reliable, valid, and unbiased comparisons across these groups. Data Source/Data Collection. Data were collected by telephone interview. The survey was administered in English and Spanish to adult general medicine patients, stratified by race/ethnicity and language (African Americans, English-speaking Latinos, Spanish-speaking Latinos, non-Latino whites) (N=1,664). Study Design/Methods. In this cross-sectional study, items were designed to be appropriate for diverse ethnic groups based on focus groups, our prior framework, literature, and cognitive interviews. Multitrait scaling and confirmatory factor analysis were used to examine measurement invariance; we identified scales that allowed meaningful quantitative comparisons across four race/ethnic/language groups. Principal Findings. The final instrument assesses several subdomains of communication, patient-centered decision making, and interpersonal style. It includes 29 items representing 12 first-order and seven second-order factors with equivalent meaning (metric invariance) across groups; 18 items (seven factors) allowed unbiased mean comparison across groups (scalar invariance). Final scales exhibited moderate to high reliability. Conclusions. The IPC survey can be used to describe disparities in interpersonal care, predict patient outcomes, and examine outcomes of quality improvement efforts to reduce health care disparities. © 2006 Health Research and Educational Trust.

Belinda L. Needham a, , Nancy Adler , Steven Gregorich , David Rehkopf , Jue Lin , Elizabeth H. Blackburn , Elissa S. Epel b a Department of Epidemiology and Center for Social Epidemiology and Population Health, 1415 Washington Heights, 2663 SPH Tower, Ann Arbor, MI 481092029, USA b Department of Psychiatry, University of California, San Francisco, USA c Division of General Internal Medicine, University of California, San Francisco, USA d Division of General Medical Disciplines, Stanford University, USA e Department of Biochemistry and Biophysics, University of California, San Francisco, USA

Objective The purpose of this study was to explore the relationship between strength of preference for vaginal delivery, delivery mode undergone, and postpartum depression. Study Design We conducted a secondary analysis of data from a longitudinal study of delivery-mode preferences. During an interview between 24-36 weeks of gestation, participants were asked whether they preferred vaginal or cesarean delivery; the strength of this preference was measured by the standard gamble metric. Depression was assessed antepartum and at 8-10 weeks and 6-8 months after delivery by using the Patient Health Questionnaire (PHQ-9). The primary outcome was PHQ-9 score at 8-10 weeks after delivery. We used multivariable regression analysis to assess the effect of strength of preference for vaginal delivery and delivery mode undergone on postpartum depression. Results Of 160 participants, 33.1% were nulliparous, and 30.6% had a previous cesarean delivery. Most of the participants (92.4%) preferred vaginal delivery, but the strength of preference varied substantially. The mean strength-of-preference score (0-1 scale; higher scores denote stronger vaginal delivery preference) was 0.658 (SD, ±0.352). A significant interaction emerged between the effects of delivery mode and vaginal delivery preference score on postpartum PHQ-9 score ( P = .047). Specifically, a stronger preference for vaginal delivery was associated with higher PHQ-9 scores among women who underwent cesarean delivery ( P = .027) but not among women who underwent vaginal delivery ( P = .761). The interaction between delivery mode and vaginal delivery preference score was no longer significant at 6-8 months after delivery. Conclusion Women who have a strong antepartum preference for vaginal delivery and deliver by cesarean may be at increased risk for depression in the early postpartum period.

Background Comprising over 600,000 patients per year, hysterectomy is the most common nonobstetrical operation performed in US women. Little is known about the natural history of the noncancerous uterine conditions leading to hysterectomy. We followed a prospective cohort of women with common pelvic problems to determine whether simple clinical characteristics could predict a subsequent hysterectomy. Study Design We recruited 762 women seeking care for abnormal uterine bleeding, chronic pelvic pain, or symptomatic uterine fibroids and ascertained their hysterectomy status during 4 years of surveillance. We collected baseline patient-reported sociodemographic and clinical data and fit Cox models to predict the effects of covariates on hysterectomy across patient age. Results There were 99 hysterectomies, resulting in 0.044 hysterectomies per person-year of observation and a 13.5% cumulative hysterectomy rate. Hysterectomy was independently predicted by multiple pelvic symptoms or symptomatic fibroids (hazard ratio [HR], 1.97; 95% CI, 1.18−3.28), previous use of a gonadotropin-releasing hormone agonist (HR, 2.54; 95% CI, 1.53−4.24), and an absence of symptom resolution (HR, 2.24; 95% CI, 1.46−3.44). Survival curves plotted for subgroups with combinations of these predictors showed an escalating risk of hysterectomy with each additional risk factor. Predicted hysterectomy rates ranged from 20%, if all 3 predictors were absent, to 95%, if all 3 were present. Conclusions For women with common pelvic problems, three easily measured clinical characteristics (symptom combination, degree of resolution, and earlier use of a gonadotropin-releasing hormone agonist) predict the likelihood of subsequent hysterectomy and can be used to inform counseling about the likely success of alternative treatments.

We describe the same-sex partnerships and sexual risk behavior of men attending sexually transmitted infection (STI) clinics in Mumbai, India. The HIV prevalence among 2,381 men sampled was 14%; 62% had a documented STI. Almost all men reported sex with women; additionally, 13% also reported having sex with other men, 13% reported sex with Hijras (male-to-female transgenders), and 11% had sex with all 3 genders. Men who had sex with men and/or Hijras as well as women, reported having greater numbers of partners, including female sex workers (FSW), and were more likely to engage in insertive anal and oral sex with women. The prevalence of HIV was higher among men having sex with Hijras (14%) or with all 3 genders (13%) than among men having sex with men and women (8%). A high proportion of men who attend STI clinics in Mumbai are behaviorally bi- or tri-sexual and have multiple partners with whom they engage in risky sex. STI/HIV prevention programs should not assume that men only have sex with women.

To identify predictors of prenatal genetic testing decisions and explore whether racial or ethnic and socioeconomic differences are explained by knowledge, attitudes, and preferences.This was a prospective cohort study of 827 English-, Spanish-, or Chinese-speaking pregnant women presenting for care by 20 weeks of gestation at 1 of 23 San Francisco Bay-area obstetrics clinics and practices. Our primary outcome measure for women aged less than 35 years was any prenatal genetic testing use compared with none, and for women aged 35 years or older, prenatal testing strategy (no testing, screening test first, straight to invasive diagnostic testing). Baseline questionnaires were completed before any prenatal test use; test use was assessed after 30 gestational weeks.Among women aged less than 35 years, no racial or ethnic differences in test use emerged. Multivariable analyses yielded three testing predictors: prenatal care site (P = .024), inclination to terminate pregnancy of a Down-syndrome-affected fetus (odds ratio 2.94, P = .002) and belief that modern medicine interferes too much in pregnancy (odds ratio .85, P = .036). Among women aged 35 years or older, observed racial or ethnic and socioeconomic differences in testing strategy were mediated by faith and fatalism, value of testing information, and perceived miscarriage risk. Multivariable predictors of testing strategy included these 3 mediators (P = .035, P.001, P = .037, respectively) and health care system distrust (P = .045). A total of 29.5% of screen-positive women declined amniocentesis; 6.6% of women screening negative underwent amniocentesis.Racial or ethnic and socioeconomic differences in prenatal testing strategy are mediated by risk perception and attitudes. Screening is not the best choice for many women. Optimal prenatal testing counseling requires clarification of risks and consideration of key attitudes and preferences regarding the possible sequence of events after testing decisions.

OBJECTIVE: To investigate how physicians tailor their recommendations for breast cancer prevention and risk reduction. DESIGN: Cross-sectional, mail survey. PARTICIPANTS: Random sample of primary care physicians in California (N=822). MEASUREMENTS AND MAIN RESULTS: Six standardized patient scenarios were used to assess how women’s breast cancer risk factors influence physicians’ recommendations for screening mammography, counseling about lifestyle behaviors, genetic testing, the use of tamoxifen, prophylactic surgery, and referral to a breast specialist. Over 90% of physicians endorsed mammography for all of the scenarios. Similarly, approximately 80% of physicians endorsed counseling about lifestyle factors for all of the scenarios. Five-year risk of developing breast cancer and family history were both strongly associated with each of the 6 recommendations. Importantly, however, physicians were more likely to endorse the discussion of genetic testing, the use of tamoxifen, and prophylactic surgery for women with a family history of breast cancer compared with women at a higher risk of developing breast cancer but without a family history. Obstetrician-gynecologists were more likely to endorse most of these practices compared with internists. CONCLUSIONS: Mammography and counseling about lifestyle behaviors are widely endorsed by physicians for breast cancer prevention and risk reduction. Whereas physicians are generally able to tailor their recommendations for prevention and risk reduction based on risk, they may perhaps underutilize genetic evaluation and newer therapeutic options for primary prevention for women who are at high risk of developing breast cancer but do not have a family history.

Background Little is known about the incorporation of breast cancer risk reduction therapies into clinical practice. Methods We assessed factors related to physicians' performance of breast cancer risk reduction practices through a self-administered survey. Subjects were California physicians in family medicine, internal medicine, or obstetrics/gynecology, identified through the AMA Masterfile. Physicians reported their breast cancer risk reduction practices (initiating patient counseling, referring patients for genetic evaluation, and prescribing tamoxifen or raloxifene) as well as barriers to counseling. Results Of 1647 eligible physicians, 822 responded. Eighty-six percent reported initiating counseling, 45% referred a patient for genetic evaluation, 31% prescribed raloxifene, and 11% prescribed tamoxifen for breast cancer prevention in the past year. The leading frequent barriers to counseling were “not enough time” (40.3%) and “insufficiently informed about risk reduction options” (19.1%). Multivariate analysis showed that a training and role factors scale was negatively associated with all risk reduction practices, and number of breast cancer diagnoses per year was positively associated with referring for genetic evaluation and prescribing chemoprevention. Conclusions Physicians in primary care specialties report participation in several breast cancer risk reduction activities. Issues related to physician training and role in risk reduction affect the implementation of these practices.

Purpose To examine the prevalence of unhealthy behaviors among a cohort of Vietnamese adolescents in California; to examine the relationship between these behaviors and school-related variables (school performance, educational risk behaviors, higher-education aspirations, and participation in extracurricular activities); and to assess the differences that may exist between males and females with regard to these factors. Methods We conducted telephone interviews with 783 Vietnamese adolescents, aged 12–17 years, recruited through telephone listings from four California counties where large Vietnamese populations reside: San Francisco, Santa Clara, Los Angeles, and Orange. Of the 783 completed interviews, 60.8% were conducted in English and 39.2% in Vietnamese. The main outcome measure is a health risk behavior scale that includes adolescents' reports of ever smoking a cigarette, sedentary vs. active lifestyle, consumption of fruits and vegetables, consumption of foods high in fat, ever drinking alcohol, and ever engaging in sexual behavior. Multiple regression analyses were employed to estimate the association among the demographic variables, acculturation, school performance, aspirations, extracurricular activities, and the overall health risk. Results Females were significantly more sedentary than males. Over one-quarter (29%) of the females reported not having participated in vigorous physical activity on 3 or more days per week, compared with just 18% of the males. Most adolescents reported they had never tried cigarettes (84%), never used alcohol (77%), and never had sex (97%). Males were more likely than females to report a higher frequency of experimentation with smoking and drinking. Overall, school performance and participation in extracurricular activities were significantly related to the health risk behavior scale. Adolescents who demonstrated at least one educational risk (ever skipped school or ever sent out of the classroom) were more likely to engage in other risky behaviors. Also, older and more acculturated adolescents were at increased risk of engaging in health-compromising behaviors. Analysis by gender revealed that the variables age, educational risk, and chance of attending college were all related to health risk behavior for both males and females. Among the boys, those who reported achieving an average grade of B or better had a decreased risk of engaging in health-compromising behaviors; however, neither extracurricular activities nor acculturation was related to health-compromising behaviors in boys. Among the girls, the reverse was true: lack of participation in extracurricular activities was related to health-compromising behaviors, whereas grades were not a significant risk factor. Conclusion Among sampled Vietnamese adolescents in California, health risk behaviors are common and inversely related to some school performance indicators. Using these indicators to identify high-risk groups could allow targeted educational programs or interventions for the mitigation of health-compromising behaviors.

Importance Prenatal genetic testing guidelines recommend providing patients with detailed information to allow informed, preference-based screening and diagnostic testing decisions. The effect of implementing these guidelines is not well understood. Objective To analyze the effect of a decision-support guide and elimination of financial barriers to testing on use of prenatal genetic testing and decision making among pregnant women of varying literacy and numeracy levels. Design, Setting, and Participants Randomized trial conducted from 2010-2013 at prenatal clinics at 3 county hospitals, 1 community clinic, 1 academic center, and 3 medical centers of an integrated health care delivery system in the San Francisco Bay area. Participants were English- or Spanish-speaking women who had not yet undergone screening or diagnostic testing and remained pregnant at 11 weeks’ gestation (n = 710). Interventions A computerized, interactive decision-support guide and access to prenatal testing with no out-of-pocket expense (n = 357) or usual care as per current guidelines (n = 353). Main Outcomes and Measures The primary outcome was invasive diagnostic test use, obtained via medical record review. Secondary outcomes included testing strategy undergone, and knowledge about testing, risk comprehension, and decisional conflict and regret at 24 to 36 weeks’ gestation. Results Women randomized to the intervention group, compared with those randomized to the control group, were less likely to have invasive diagnostic testing (5.9% vs 12.3%; odds ratio [OR], 0.45 [95% CI, 0.25-0.80]) and more likely to forgo testing altogether (25.6% vs 20.4%; OR, 3.30 [95% CI, 1.43-7.64], reference group screening followed by invasive testing). Women randomized to the intervention group also had higher knowledge scores (9.4 vs 8.6 on a 15-point scale; mean group difference, 0.82 [95% CI, 0.34-1.31]) and were more likely to correctly estimate the amniocentesis-related miscarriage risk (73.8% vs 59.0%; OR, 1.95 [95% CI, 1.39-2.75]) and their estimated age-adjusted chance of carrying a fetus with trisomy 21 (58.7% vs 46.1%; OR, 1.66 [95% CI, 1.22-2.28]). Significant differences did not emerge in decisional conflict or regret. Conclusions and Relevance Full implementation of prenatal testing guidelines using a computerized, interactive decision-support guide in the absence of financial barriers to testing resulted in less test use and more informed choices. If validated in additional populations, this approach may result in more informed and preference-based prenatal testing decision making and fewer women undergoing testing. Trial Registration clinicaltrials.gov Identifier:NCT00505596