Psychosocial risk factors for HIV sexual risk among Indian men who have sex with men.

Indian men who have sex with men (MSM) are at increased risk for HIV compared to the general Indian population. Psychosocial factors may be uniquely associated with HIV risk among Indian MSM and may moderate the beneficial impact of standard HIV prevention approaches. Psychiatric diagnostic interviews and psychosocial and sexual risk assessments were conducted among 150 MSM in Mumbai, India. Logistic regression was employed to examine the association of psychiatric disorders and psychosocial problems to recent sexual risk behavior. Twenty-five percent of participants reported engaging in unprotected anal sex (UAS) during their last sexual contact with a man. Men who were married to a woman were more likely to have engaged in UAS during their last sexual contact with a man (35% vs. 17%, p=0.018). In multivariable models, significant predictors of engaging in UAS were current major depression (adjusted odds ratio [AOR]=2.61; 95% confidence interval [CI] 1.07, 6.39) and number of stressful life events (AOR=0.91; 95% CI 0.83, 0.99). Alcohol dependence, anxiety, and self-esteem were not associated with engaging in UAS. Indian MSM with depression are at higher odds of engaging in UAS compared to MSM without depression. HIV prevention programs for Indian MSM may benefit from incorporating treatment or triage for mental health problems.

Multiple chlamydia infection among young women: comparing the role of individual- and neighbourhood-level measures of socioeconomic status.

BACKGROUND: Young women have the highest burden of chlamydia infections, and socioeconomic disparities exist. Individual-level measures of socioeconomic status (SES) may be difficult to assess for young women. The authors examined whether neighbourhood SES provides a useful measure in comparison with individual-level SES with respect to the burden of multiple chlamydia diagnoses. METHODS: In a study of young women with chlamydia (n=233; mean age =21 years), multiple infections were assessed with self-report and follow-up testing. General estimating equations and pseudo-R(2) were used to assess the roles of individual-level SES (education and employment) and neighbourhood-level SES (percentage of people in census tract of residence below poverty) on multiple chlamydia diagnoses. RESULTS: Neither education nor employment was associated with multiple chlamydia diagnoses. Women living in high-poverty areas were significantly more likely than those living in low-poverty areas to have multiple chlamydia diagnoses (adjusted OR 3.46, 95% CI 1.18 to 10.15). This neighbourhood-level poverty measure improved model fit by 17%. CONCLUSIONS: Neighborhood-level poverty may provide a better measure of SES than individual-level variables as a predictor of multiple chlamydia diagnoses in young women and can be useful when valid measures of individual-level SES are unavailable.

Tobacco education and counseling in obstetrics and gynecology clerkships: a survey of medical school program directors.

The 16,000 medical students completing OB/GYN clerkship programs each year provide a unique opportunity to motivate and mentor students in facilitating tobacco cessation. To determine the scope of current tobacco teaching in obstetrics/gynecology (OB/GYN) education at US medical schools and to assess opportunities for including new tobacco teaching, a 28-question survey was administered to directors and assistant directors at US medical school OB/GYN clerkship programs. Surveys were completed at 71% of schools. Only 9% reported having at least 15 min of dedicated teaching time for improving tobacco cessation skills. Nearly three-fourths of respondents reported teaching students how to intervene to reduce smoking during a work-up in the OB/GYN clinic, but only 43% reported that students would know where to refer someone wishing to quit. Only a third of respondents reported teaching students both to intervene with and refer OB/GYN patients who smoke. These findings suggest that although medical students see many OB and GYN patients who smoke, they have few opportunities to learn comprehensive cessation skills during their clerkships.

Effect of teenage parenthood on mental health trajectories: does sex matter?

Rates of teenage pregnancy and parenthood in the United States remain high. Although many consequences of teenage parenthood have been well studied, little prospective research has examined its effect on mental health. This study aims to better understand the impact of teenage parenthood on mental health and to determine whether sex modifies this relation. Using data from the National Longitudinal Survey of Youth, 1997 (1997-2006), and a matched cohort design, the authors compared changes in the mental health of parenting teenagers and nonparenting teenagers over 6 years of follow-up with mixed-effects regression. The results indicate that mental health improved for all teenagers over 6 years of follow-up. Furthermore, overall, teenage parenthood was not associated with changes in mental health; however, sex modified this relation. Although the mental health of teenage fathers improved at a faster rate compared with nonparenting teenage males, teenage mothers improved at a slower rate compared with nonparenting teenage females. Psychological health has important implications for both the teenage parent and the child. Future studies should aim to better understand the mechanisms through which teenage parenthood impacts mental health among both males and females, and interventions should be developed to ensure mental health among young parents.

Like father, like son: the intergenerational cycle of adolescent fatherhood.

OBJECTIVES: Strong evidence exists to support an intergenerational cycle of adolescent fatherhood, yet such a cycle has not been studied. We examined whether paternal adolescent fatherhood (i.e., father of study participant was age 19 years or younger when his first child was born) and other factors derived from the ecological systems theory predicted participant adolescent fatherhood. METHODS: Data included 1496 young males who were interviewed annually from the National Longitudinal Survey of Youth 1997. Cox regression survival analysis was used to determine the effect of paternal adolescent fatherhood on participant adolescent fatherhood. RESULTS: Sons of adolescent fathers were 1.8 times more likely to become adolescent fathers than were sons of older fathers, after other risk factors were accounted for. Additionally, factors from each ecological domain-individual (delinquency), family (maternal education), peer (early adolescent dating), and environment (race/ethnicity, physical risk environment)-were independent predictors of adolescent fatherhood. CONCLUSIONS: These findings support the need for pregnancy prevention interventions specifically designed for young males who may be at high risk for continuing this cycle. Interventions that address multiple levels of risk will likely be most successful at reducing pregnancies among partners of young men.

Economic dependence and unprotected sex: the role of sexual assertiveness among young urban mothers.

In the USA, sexual intercourse is the leading route of human immunodeficiency virus transmission among women, primarily through their main partner. Because male condom use is not directly under a woman's control, gender inequalities may help shape this sexual risk behavior. To examine this association, data came from follow-up interviews of young, primarily minority, pregnant women enrolled in a prospective, randomized controlled trial. Specifically, we aimed to determine the relationship between economic dependence on a male partner and condom use, and to establish whether this relationship was mediated by sexual assertiveness. Overall, 28% of women reported being economically dependent on a male partner. Young women dependent on a male partner were 1.6 times more likely to report not using a condom at last sex than women not dependent on their partner (95% confidence interval = 1.11-2.32; p = 0.01). Sexual assertiveness mediated the relationship between economic dependence and condom use (Sobel = 2.05, p = 0.04). Coupled with past research, this study supports the premise that sexual behaviors may be rooted in a complex web of social determinants. Addressing gender inequalities in contextual factors may promote healthier decisions within sexual relationships.

Racial differences in age at first sexual intercourse: residential racial segregation and the black-white disparity among U.S. adolescents.

OBJECTIVES: The age of adolescents at first sexual intercourse is an important risk factor for sexually transmitted diseases (STDs) and adolescent pregnancy. Black adolescents are at higher risk than white adolescents for first sexual intercourse at younger ages as well as STDs and pregnancy. Individual- and family-level factors do not fully explain this disparity. We examined whether five dimensions of black-white residential racial segregation can help explain the racial disparity in age at first sexual intercourse. METHODS: Using the National Longitudinal Survey of Youth 1997 and U.S. Census 2000 data, we performed multiple hierarchical discrete time-to-event analyses on a nationally representative cohort of adolescents followed since 1997. Although the cohort study is ongoing, we used data from 1997 through 2005. RESULTS: Concentration and unevenness significantly modified the association of race and age at first sexual intercourse. However, stratified results suggested differences in the effect of race on age at first sexual intercourse at each level of segregation across dimensions of segregation. CONCLUSIONS: Residential racial segregation may modify the black-white disparity in risk of first sexual intercourse at younger ages, but these associations are complex. Future studies should be conducted to elucidate the causal mechanisms.

Residential racial segregation and racial differences in sexual behaviours: an 11-year longitudinal study of sexual risk of adolescents transitioning to adulthood.

BACKGROUND: Determining the underlying causes of racial disparities in sexually transmitted infections (STIs) is important. In the USA, rates of the most common STIs range from 5 to 20 times higher for African-Americans compared to Caucasians, and the health consequences of STIs can be serious. Residential racial segregation results in very different contexts for individuals and may be an important determinant of sexual risk. The purpose of this study was to examine how segregation and race interact to impact the age trajectory of sexual risk behaviours. METHODS: Using 11 years of data from the National Longitudinal Survey of Youth 1997 (1997-2007) and 2000 Census data, the authors performed three-level hierarchical linear regression to examine the associations between hypersegregation, race and a sexual risk behaviour index among black and white non-Hispanic adolescents as they transition to adulthood. RESULTS: Through most of the teenage years, African-Americans are at higher sexual risk than Caucasians. However, by age 19, Caucasians are at higher risk. Hypersegregation was not associated with increased sexual risk index score on average and did not impact the trajectory of the race-sexual risk association. CONCLUSIONS: The authors did not find any evidence that hypersegregation was associated with the sex risk index or that it modified the race-sex risk association as individuals got older. Future studies should examine whether segregation is associated with other causes of STI/HIV acquisition risk, such as sexual network patterns.

Racial disparities in age at preventable hospitalization among U.S. Adults.

BACKGROUND: Similar to the well-documented racial inequities in health status, disease burden, healthcare access, and hospitalization, studies have generally found higher rates of hospitalization resulting from ambulatory care-sensitive conditions for blacks compared to whites. Beyond identifying disparity in rates of disease or risks of hospitalization, identifying disparity in age at hospitalization may provide deeper insight into the social and economic effects of disparities on individuals, families, and communities. PURPOSE: The objective of this paper is to evaluate potential racial disparities in age of preventable hospitalizations as measured by ambulatory care-sensitive conditions. METHODS: Differences in mean age at hospitalization for ambulatory care-sensitive conditions were evaluated in a nationally representative sample of 6815 hospital discharges using the 2005 National Hospital Discharge Survey. Linear regression using robust SE procedures was used to evaluate differences among nine chronic and three acute conditions. Analyses were conducted in 2008. RESULTS: After adjustment for sociodemographic characteristics, blacks were hospitalized > or =5 years earlier than whites across all conditions combined and for chronic and acute conditions separately. The largest differences were seen for uncontrolled diabetes (adjusted difference= -12.0 years) and bacterial pneumonia (adjusted difference= -7.5 years). CONCLUSIONS: Racial disparities in age at preventable hospitalization exist across a spectrum of conditions. This difference in age at hospitalization places an undue burden on individuals, families, and society with long-term health and financial sequelae. Promoting equity in disease prevention, management, and treatment should be a priority of any healthcare reform efforts.

Rates of skin cancer screening and prevention counseling by US medical residents.

OBJECTIVE: To determine factors related to residents' self-reported skill level for the skin cancer examination (SCE). DESIGN: Survey of residents in November 2003. SETTING: Four US residency programs. PARTICIPANTS: Medical residents in family medicine, pediatrics, obstetrics and gynecology, and internal medicine and specialists. MAIN OUTCOME MEASURE: Proportion of residents reporting their current skill level for the performance of the SCE. RESULTS: Of 454 surveys distributed, 342 residents completed the survey (75.3% response rate). Clinical training for the SCE during residency was infrequent. During residency, 75.8% were never trained in the SCE, 55.3% never observed an SCE, and 57.4% never practiced the examination. Only 15.9% of residents reported being skilled in the SCE. However, the conduct of 4 SCEs (or slightly more than 1 per each year of residency) was associated with manifold increases in self-reported skill levels. CONCLUSIONS: Information now collected from 7 medical schools and 4 residency programs underscores the need for more supervised opportunities to enable physicians in training to perform an SCE during routine patient examinations.