Immunization and vaccine-preventable illness, United States, 1992 to 1997.

In contrast to the 1980s, immunization rates increased dramatically in the United States in the mid-1990s. Three-quarters of all 2-year-olds had received all recommended immunizations in 1997 as compared to just over one-half in 1992. Immunization rates for individual vaccines have reached 90 percent for three of the vaccines--measles, mumps, rubella; pollo; and Haemophilus influenzae type b (Hib). The vaccine for diphtheria, tetanus and pertussis, however, and the newer vaccine for hepatitis B have not yet reached 90 percent of 2-year-olds. The rising immunization levels in young children have resulted in declining incidence of almost all of the vaccine-preventable illnesses. Cases of measles and Hib have declined 95 percent and the incidence of rubella and congenital rubella, hepatitis B and mumps has also declined. Pertussis (whooping cough), however, continued its pattern of periodic increases and decreases. This lack of improvement is probably due to a combination of lower immunization levels for pertussis and waning immunity in previously immunized adolescents and young adults. Federal efforts such as the President's Childhood Immunization Initiative along with its Vaccines for Children program have been credited for a great deal of this improvement. These programs increased public awareness of the need for and access to immunizations, better tracking of immunizations and vaccine-preventable illnesses and have also removed cost barriers to receipt of such protection. At the same time, new vaccines (against chickenpox and rotavirus) and safer versions of older vaccines (pertussis) have been brought into widespread use. Children can now be vaccinated against increasing varieties of childhood diseases. While progress in immunization has been good, areas in need of improvement remain. Pertussis continues to be a problem both in terms of incidence and immunization levels. Also, immunization levels differ significantly by poverty level and race and ethnicity. Black, Hisparic, American Indian and Asian children are less likely to be fully immunized than non-Hispanic white children and poor children are less likely to be fully immunized than nonpoor children.

The effect of gaps in health insurance on continuity of a regular source of care among preschool-aged children in the United States.

OBJECTIVE: To estimate the prevalence and length of gaps in health insurance coverage and their effect on having a regular source of care in a national sample of preschool-aged children. DESIGN: Follow-up survey of a nationally representative sample of 3-year-old children in the US population by phone or personal interview. PARTICIPANTS: A total of 8129 children whose mothers were interviewed for the 1991 longitudinal Follow-up to the National Maternal and infant Health Survey. MAIN OUTCOME MEASURES: Report of any gap in health insurance for the children, the length of the gap, and the number of different sites where the children were taken for medical care as a measure of continuity of a regular source of care. RESULTS: About one quarter of Us children were without health insurance for at least 1 month during their first 3 years of life. Over half of these children had a health insurance gap of more than 6 months. Less than half of US children had only one site of care during their first 3 years. Children with health insurance gaps of longer than 6 months were at increased risk of having more than one care site (odds ratio = 1.52; 95% confidence interval, 1.19 to 1.96). This risk further increased when an emergency treatment was discounted as a multiple site of care. CONCLUSIONS: Having a gap in health insurance coverage is an important determinant for not having a regular source of care for preschool-aged children. This finding is of concern, given the sizable percentage of children in the United States who lacked continuous health care coverage during a critical period of development.

Vaccine-preventable illness in U.S. children 1980-1992.

For at least a decade after the licensure of vaccines to prevent major childhood diseases, incidence of these diseases decreased. However, in the mid-to-late-1980s, four major childhood illnesses showed increases in the number of cases and the case rate, and the United States experienced epidemics of measles, mumps, rubella and whooping cough. The measles epidemic was the most severe of the four with over 55,000 cases, 11,000 hospitalizations, and 130 deaths reported across the country between 1989 and 1991. Children were hit the hardest by these epidemics. Predating these epidemics was a decline in the immunization levels of 2-year-olds. This decline coincided with vaccine price increases, an increase in the percentage of children in poverty and a decline in the rate of poor children receiving Aid to Families with Dependent Children (AFDC) and Medicaid. An estimated 100,000 excess cases of disease resulted from the low levels of immunization and consequent epidemics. While immunization rates have increased in recent years, it is important to continue our progress in this area in order to protect children from vaccine-preventable infectious diseases.

AIDS knowledge, perceived risk and prevention among adolescent clients of a family planning clinic.

In a survey that measured AIDS knowledge, perceived risk and prevention among 404 sexually active adolescent women who were family planning clinic patients in Baltimore, knowledge about AIDS was high, with the average respondent answering seven out of nine questions correctly. Slightly more than half of the teenagers reported some degree of perceived risk that they could get AIDS. However, perceived AIDS risk was not predictive of condom use at last intercourse. The strongest predictor of condom use was having asked a partner to use one, suggesting that adolescent women may exert a greater influence on condom use than has been previously assumed. The analyses result in recommendations that personalized AIDS prevention programs be integrated into family planning programs, that adolescent clients be advised to use condoms with spermicides, and that they be assisted in acquiring the social skills needed to negotiate condom use with partners.

Cancer screening services for the elderly.

The reported practices and recommendations of primary care physicians with regard to cancer screening of elderly patients (65 years and older) were studied in a 1987 survey of 400 Maryland physicians. More than 90 percent of physicians in four specialties studied reported providing digital rectal examinations, physical breast examinations, and mammography to the elderly. However, only 54 percent of obstetrician-gynecologists and 68 percent of general practitioners provided sigmoidoscopy, 70 percent of obstetrician-gynecologists provided stool guaiac slide tests, 74 percent of general practitioners provided breast self-exam instruction, and 79 percent of internists provided Pap tests. Physicians were asked what screening intervals they recommended for each test for asymptomatic elderly patients. These reports were compared with current American Cancer Society (ACS) recommendations. Large proportions of physicians in four specialties recommended sigmoidoscopy and mammography less often than the ACS recommended. More than 20 percent of physicians in the four specialties believed the elderly do not need routine sigmoidoscopy. Most physicians (90 percent or more) recommended Papanicolaou tests more often than the ACS recommended. Specialty and young physician age were the best predictors of physicians' overall adherence to ACS recommendations for cancer screening schedules.

Women and health care communication.

Research bearing on the issue of gender differences in patient-provider communication is discussed, and recommendations for future research and for patient education and counseling are offered. Based on limited available evidence, women appear to receive more health care communications and more health information than men, possibly due to women's superior general communication skills. Provider gender may also affect the communication process, and congruence between patient and provider gender could produce more effective communication under some circumstances.

Practice changes in response to the malpractice litigation climate. Results of a Maryland physician survey.

Data from a 1987 survey of Maryland physicians in three specialties (internal medicine, family or general practice, and obstetrics-gynecology) were used to study the types of changes physicians have made in their practices during the last 2 years as a result of the current malpractice litigation climate. Overall, 51% reported making some type of practice change. The practice changes that physicians reported reflect both risk-reduction (e.g., increased use of tests) and risk-avoidance (e.g., cutting back high-risk patients) strategies, although risk-reduction actions were reported more frequently. Raising patient fees was also reported. Specialty predicts whether or not physicians make each type of change; in particular, obstetrician-gynecologists are more likely to report practice changes of all types. Prior litigation experience does not, in general, predict practice changes. The implications of the types of changes reported for access to care and costs of care were considered.

Pap testing intervals. Specialty differences in physicians' recommendations in relation to women's pap testing behavior.

Using data from a survey of internists, family and general practitioners, and obstetricians and gynecologists, and of women in Maryland, this article examines congruence between physicians' recommendations and women's Papanicolaou (Pap) testing behavior. Both the specialty of the physicians and the age of the women are considered. The majority of all three physician specialties recommended annual Pap tests for all their patients. However, the internists and family or general practitioners were less likely to recommend annual Pap smears for their elderly patients than for their younger patients. Obstetrician-gynecologists were consistently more likely than the other specialties to recommend annual Pap tests, to send postcards to their patients reminding them to come in for Pap tests, and to view themselves as successful in inducing their patients to come in for routine Pap testing. Both the physicians and the women reported that elderly women were less likely than younger women to receive care from obstetrician-gynecologists. Women's reported Pap testing behavior indicated that they received Pap tests with far less frequency than the physicians recommended. Older age was related to less frequent Pap testing, while having a visit with an obstetrician-gynecologist was related to increased frequency. Findings indicate the need for education of physicians about methods of improving women's attendance for Pap testing and of women about the importance of routine Pap testing.

Malpractice claims experience associated with fertility-control services among young obstetrician-gynecologists.

Threatened and actual medical malpractice claims associated with delivery of fertility-control services are studied in a national sample of 1,420 recently trained obstetrician-gynecologists who had been in practice an average of 3 years at the time of the survey. Nine percent of respondents report having been threatened with a fertility-control-related lawsuit, and 5.5% report being named as a defendant in such a suit. The types of services named most frequently as the basis of threatened lawsuits are sterilizations and abortions. In logistic regression analyses, variables found to significantly increase the risk of both threatened and actual lawsuits are number of years in practice and number of abortions provided during the last year of practice. Treatment of more minority patients significantly reduces the risk of both threatened and actual claims. Type of practice arrangement, physician gender, and attitudes toward physician-patient communication are among the variables found not to affect the risk of litigation. Implications for provision of fertility-control services are discussed.

Couples at risk for transmission of alcoholism: protective influences.

A two-generation, sociocultural model of the transmission of alcoholism in families was operationalized and tested. Sixty-eight married children of alcoholic parents and their spouses were interviewed regarding dinner-time and holiday ritual practices in their families of origin, and heritage and ritual practices in the couples' current generation. Coders rated transcribed interviews along 14 theory-derived predictor variables, nine for the family of origin and five for the current nuclear family. Multiple regression analysis was applied in a two-step hierarchical method, with the dependent variable being transmission of alcoholism to the couple. The 14 predictor variables contributed significantly (p less than .01) to the couple's alcoholism outcome. A general theme of selective disengagement and reengagement for couples in families at risk for alcoholism recurrence is discussed.

Delivery of fertility control services by male and female obstetrician-gynecologists.

Sex differences in the delivery of fertility control services were explored in a national survey of 1420 recently trained obstetrician-gynecologists in active practice. Women were found to be more likely than men to provide abortion services but less likely than men to provide amniocentesis and certain infertility services. Women were found to contribute less than their proportionate share of two services for which volume was measured: artificial inseminations and sterilizations. Physician gender, however, was a less important predictor of volume of sterilizations delivered than were a set of practice-related variables. Overall our findings suggest that the increased representation of women among obstetrician-gynecologists could influence the delivery of a few specific services.

PIP: Sex differences in the delivery of fertility control services were explored in a 1984 national survey of 1420 recently trained obstetrician-gynecologists in active practice in the US. The survey consisted of a telephone interview and a self-administered questionnaire mailed to respondents to the interview. Respondents were located in all 50 states and had been in practice an average of 3 years at the time of the survey. Women were found to be more likely to provide abortion services but less likely than men to provide amniocentesis and certain infertility services. Women were found to contribute less than their proportionate share of 2 services for which volume was measured: artificial inseminations and sterilizations. Physician gender, however, was a less important predictor of volume of sterilizations delivered than were a set of practice related variables. Overall the findings suggest that the increased representation of women among obstetrician-gynecologists could influence the delivery of a few specific services. While women were significantly more likely than men to be supportive of greater patient decision power in the matter of sterilization, attitudes were not found to be associated with number of sterilizations performed. The strongest predictor of sterilization volume was the physician's number of patient encounters/week; physicians treating more patients/week provided more sterilizations during the last year. Other predictors of sterilization volume that were stronger than gender included practicing in a multispecialty group; practicing in the north central or southern states; and practicing in a nonurban area.

Pap testing: opinion and practice among young obstetrician-gynecologists.

Since 1976, contradictory recommendations by a number of groups (including the American Cancer Society, the National Cancer Institute, a National Institutes of Health Consensus Development Conference, the Canadian Task Force on Cervical Cancer Screening Programs, and the American College of Obstetricians and Gynecologists) on the timing of Pap testing--including age to begin testing, appropriate frequency of testing, and age to discontinue testing--have been communicated to both physicians and consumers. The opinions and practices of a U.S. national sample of recently trained obstetrician-gynecologists, whose professional association continues to endorse annual Pap tests, were investigated and compared with key points from the various recommendations. The appropriateness of the recommendations themselves is not addressed. Findings show that respondents are aware of recommendations for less frequent Pap testing, but they believe that women should generally receive annual Pap tests and that regular Pap testing should not be discontinued among the elderly. While the intensity of Pap testing services varies by type of practice arrangement, such variation does not occur for opinions regarding Pap testing, with one exception: Those practicing in multispecialty groups (including health maintenance organizations) are more likely to endorse routine Pap testing for elderly women if they see elderly women in their practices. Thus, the physicians in this study are not adhering to recommendations for Pap testing on a less-than-annual basis or for discontinuance in the elderly.

Sex differences in the practice patterns of recently trained obstetrician-gynecologists.

Sex differences in practice patterns, as modified by family roles, are investigated in a national survey of 1420 active obstetrician-gynecologists who graduated from medical school between 1974 and 1979. Women are more likely than men to be practicing in multispecialty groups, and men are more likely than women to be practicing in obstetrics-gynecology partnerships. On average, men and women report working over 60 hours per week. In all practice arrangements except academic medicine, women work fewer total hours per week, although the differences are small and translate into significantly fewer patient encounters than men in only two practice arrangements: partnerships and multispecialty groups. When marital status and presence of children under age 18 are controlled, significant sex differences in hours worked remain only for married respondents with children. Family roles have an opposite effect on hours of work reported by men and women, decreasing the number of hours worked by women and increasing the number worked by men.

Abortion attitudes and performance among male and female obstetrician-gynecologists.

Recently trained female obstetrician-gynecologists in active practice have more favorable attitudes toward abortion than do recently trained male ob-gyns, and the former also are more likely to provide abortions. However, since female providers perform fewer abortions than do male providers, women's contribution to the overall volume of abortions performed is no higher than expected. In a multivariate analysis, abortion attitudes proved to be the strongest predictor of whether or not a physician provides abortions, but practice-related variables are stronger predictors of the number of abortions performed. Factors related to policy issues, such as state funding of abortions for poor women and hospital policies with respect to abortion provision, had statistically significant effects on physicians' abortion performance.

PIP: Recently trained US female obstetrician-gynecologists in active practice have more favorable attitudes toward abortion than do recently trained male ob-gyns, and the former also are more likely to provide abortions. However, since female providers perform fewer abortions than do male providers, women's contribution ot the overall volume of abortions performed is no higher than expected. In a multivariate analysis, abortion attitudes proved to be the strongest predictor of whether or not a physician provides abortions, but practice-related variables are stronger predictors of the number of abortions performed. Factors related to policy issues, such as state funding of abortions for poor women and hospital policies with respect to abortion provision, had statistically significant effects on physicians' abortion performance. Of course, it is possible that rather than determining the physician's abortion performance, some of the practice-related characteristics studied here might reflect the physician's selection of a practice setting compatible with his or her abortion preferences, or might reflect the physician's influence on the practice site.

Physician gender and the physician-patient relationship: recent evidence and relevant questions.

Despite criticisms of the quality of health care for women and considerable research on sex differences in illness behavior and utilization of health services, little research has addressed the potential impact of physician gender on the physician-patient relationship and its outcomes. With the entry of more women into the medical profession, opportunities to investigate effects of physician gender will increase. A theoretical rationale for expecting physician gender to affect the key dimensions of the interactive physician-patient relationship (communication of information, affective tone, negotiative quality) and its outcomes (satisfaction, compliance, health status) is presented. Physician gender might impact on the relationship through three mechanisms: sex differences among physicians, particularly with respect to sex-role attitudes; patients' different expectations of male and female physicians; or increased status congruence between physician and patient in same-sex, as compared to opposite-sex, physician-patient dyads. Recent research related to these topics is discussed and found to support the plausibility of these mechanisms of potential gender effects. Some methodological suggestions for future research are presented, including the suggestion that future research identify specific conditions under which physician gender effects might be more salient.

KIE: The authors hypothesize that physician gender could have an effect on patient satisfaction, compliance, and health status through the mechanisms of the physician patient relationship. They review the literature on three aspects of this relationship: physicians' sex role attitudes, patients' differing expectations of male and female physicians, and communication and rapport in same-sex versus opposite-sex physician patient interactions. They conclude that recent research supports the plausibility of their hypothesis and suggest methods for identifying specific conditions where the importance of physician gender might be demonstrated.

Disrupted family rituals; a factor in the intergenerational transmission of alcoholism.

When one or both parents in a family are alcoholics, their children are more likely to become alcoholics if family rituals--surrounding dinner time, evenings, holidays, weekends, vacations and visitors--are disrupted during the period of heaviest parental drinking.