Spouse abuse, patient-physician communication, and patient satisfaction.

INTRODUCTION: This study examines differences in physician communication and patient satisfaction with physician care, contrasting women who have and have not been abused by spouses or intimate partners. METHODS: A nationally representative sample of women participated in a telephone survey including questions on spouse abuse, health status, satisfaction with physicians, and communication with physicians. This article uses data from the survey describing 1,082 married or cohabitating respondents 18-64 years of age who had a regular physician and made at least one doctor visit in 1992. RESULTS: Overall, 7.3% of respondents reported being physically abused by a spouse during the previous year. Abused women were much more likely than other women to report both poor communication and dissatisfaction with physicians. Only 9.7% of the abused women had discussed the abuse with a physician. Controlling for socio-demographic and health-related factors in logistic regression analysis, we found that spouse abuse more than doubled respondents' odds of being dissatisfied with physician care. When the quality of patient-physician communication was added to the model, the influence of spouse abuse became insignificant. Instead, women reporting poor communication with physicians were four times more likely than others to be dissatisfied with physician care. CONCLUSIONS: Spouse abuse creates barriers to patient-physician communication, and poor communication contributes to lower satisfaction with care. Careful interviewing by trained clinicians is essential to identify and address abusive situations and to prevent further damage to women's physical and mental health.

Cost-effective policies for cervical cancer screening. An international review.

Screening programmes for cervical cancer have been credited with reducing the incidence of and mortality from cervical cancer. The main components of these screening programmes are: (i) their level of organisation; (ii) the age at which women begin screening; (iii) the age at which women discontinue screening; (iv) the interval between repeat screens; (v) the frequency at which the programmes provide screening; and (vi) the response to an abnormal screening test. However, not all screening programmes are equally efficient and differences in programme components can result in big differences in their cost effectiveness. Studies that employ cost-effectiveness analysis (CEA) to examine the efficiency of different programme components can inform the development of cost-effective programmes. This article presents findings of an international review of cost-effectiveness studies of cervical cancer screening. These studies consistently find that certain types of programmes are more cost effective than others. Programmes that are centrally organised and implemented by the public sector are reported to be more cost effective than those that use public funds for screening at other medical visits (convenience screening), or those that provide guidelines for healthcare professionals and the public to promote spontaneous discretionary screening. There is also substantial agreement about the cost effectiveness of other programme components. When multiple screenings are possible, studies report that they should generally begin at age 25 to 35 years and end at age 65 to 70 years, although it is important that older women have 3 normal Papanicolaou (Pap) smears before the discontinuation of screening. The interval for repeat screens that is reported to provide the best balance between cost and life-years saved is between 3 and 5 years. However, when a choice must be made between screening more women fewer times, or screening fewer women more times, most studies indicate that it is more cost effective to prioritize resources to obtain at least one screening for each woman. The screening of previously unscreened and high-risk populations has been shown to be especially cost effective. Despite this agreement, many studies report that models of the cost effectiveness of screening for cervical cancer are sensitive to a number of parameters. Changes in the attendance rate of the programme, the quality of the Pap smear, and the cost of the Pap smear can markedly change the cost effectiveness of a screening programme. Finally, this review discusses different perspectives of social choice analysis (e.g. CEA and cost-benefit analysis), when the objective is to prevent cervical cancer and the options are to screen, detect and treat, to reduce behavioural risk factors, and/or to pursue promising biological research.

Prevalence of violence and its implications for women's health.

This study estimates the lifetime prevalence of violent experiences and their relationship to health and the use of health services in U.S. women aged 18-64 years. The Commonwealth Fund's 1998 Survey of Women's Health provides a nationally representative sample. Use of weighted data allows projections to be made to the U.S. population. Over four of ten women in the U.S. are likely to have experienced one or more forms of violence, including child abuse (17.8%), physical assault (19.1%), rape (20.4%), and intimate partner violence (34.6%). In multivariate logistic regression models that control for sociodemographic characteristics, violence-particularly intimate sexual violence-is significantly related to poorer physical and mental health and increased problems with access to medical care. Only one-third of women who experience violence have discussed it with a physician. Health care professionals need to initiate the conversation about violence and offer referrals for needed services.

Partner-specific condom use among adolescent women clients of a family planning clinic.

Because inconsistent condom use could put adolescent women at an increased risk for sexually transmitted diseases, it is important to understand when and with whom they use condoms. This study examined partner-specific condom use over time among adolescent women. The data were from a clinic-based, prospective study of 308 adolescent women who had at least one sex partner during a 6-month follow-up. Their condom use was examined with three types of partners: exclusive, nonexclusive primary, and nonexclusive secondary. Predictors of consistent condom use (using condoms 100% of the time with a specific partner) were explored in a multiple logistic regression analysis. Consistent condom use was more likely to occur in shorter relationships (less than 3 months) and with partners who preferred condoms for contraception. It was no more likely to occur with nonexclusive partners than with exclusive partners, and it was somewhat less likely to occur among consistent oral contraceptive users. These findings emphasize the importance of educating adolescent women to introduce and maintain condom use with all partners.

PIP: More than 50% of sexually active adolescents have more than 1 sex partner. Since the inconsistent use of condoms may place sexually active youths at increased risk of infection with sexually transmitted diseases, it is important to determine and understand when and with whom adolescents use condoms. Using 1988 interview data from a family planning clinic on 308 non-pregnant, unmarried women aged 11-18 years who had at least 1 sex partner over a 6-month follow-up period, this study investigated partner-specific condom use over time. 77% of respondents were Black, 89% urban, and of average age 16. Among those who had engaged in sexual intercourse by baseline, mean age at first intercourse was 14.5 years with an average 2.9 sex partners. 81.8% had 1 exclusive sex partner over the follow-up period and 58% had mothers who were themselves teenage mothers. Multiple logistic regression was used to analyze predictors that respondents would use condoms during 100% of sexual intercourse encounters with each of exclusive, nonexclusive primary, and nonexclusive secondary partners. Analysis revealed that consistent condom use was more likely to occur in relationships lasting less than 3 months and with partners who preferred condoms for contraception. Consistent condom use was no more likely to occur with nonexclusive partners than with exclusive partners, and was somewhat less likely to occur among consistent oral contraceptive users. These findings highlight the need to teach adolescents to begin and continue using condoms with all sex partners.

The role of social support in breastfeeding promotion: a literature review.

The current worldwide decline in the initiation and duration of breastfeeding has increased the need for effective breastfeeding promotion. Promotion policies and programs need to be sensitive to those factors that may help or hinder a mother in her efforts to breastfeed. Such factors include sociodemographic characteristics, maternal employment, and social support. Social support that increases breastfeeding includes emotional, tangible, and educational components from both informal social network members (male partner, mother, family/friends) and professional network members (health care professionals, lactation consultants). Conversely, negative social support may decrease breastfeeding.

Teacher assessments of children's behavioral disorders: demographic correlates.

The relationship of demographic variables to teacher reports of behavior problems in six-to-eight-year-olds was examined. Contrary to previous research findings associating teacher-reported problems, with poverty and gender, multivariate analyses found significant associations only for ethnicity and caretakers' marital status. Implications for research on the impact of demographic factors on children's behavior problems and school performance are discussed.

Violence and gynecologic health in women <50 years old.

OBJECTIVE: Our purpose was to examine, in women aged 18 to 49, the relationship of violent experiences (child abuse, violent crime, spouse abuse) to gynecologic problems. STUDY DESIGN: Data from 1599 participants in a randomized, sociodemographically representative telephone survey of U.S. women were used. Gynecologic problems wer measured by self-report of receiving a physician's diagnosis of severe menstrual problems, a sexually transmitted disease, or a urinary tract infection. Statistical analyses used were the chi2 test and multiple logistic regression. RESULTS: A total of 31.5% of participants reported a diagnosis of gynecologic problems in the past 5 years. Those with problems were more likely to report childhood abuse, violent crime victimization, and spouse abuse. In logistic regression models controlling for sociodemographic factors and access to medical care, violence events remained significantly associated with gynecologic problems. CONCLUSIONS: A history of gynecologic problems may indicate that a patient has been harmed by violence. However, all women are at risk of being harmed by violence, and a violence history should be obtained as part of the intake protocol for all patients. Physicians need to be prepared to provide information about local community services, including counseling, domestic violence centers, shelters, and advocacy groups.

Physician beliefs about victims of spouse abuse and about the physician role.

Our purpose was to measure the beliefs of physicians about victims of spouse abuse and to examine factors related to holding positive (e.g., supportive) and negative beliefs about providing services to victims of domestic violence. This was a total site sample of 150 physicians (76 responded; RR 51%), surveyed at one time, practicing in a large general hospital and the surrounding urban/periurban area. Four specialities are represented: emergency medicine, family practice, obstetrics-gynecology, and psychiatry. Three aspects of beliefs are measured: beliefs toward physician role in assisting victims of spouse abuse, beliefs about victims of spouse abuse, and beliefs about resources available to physicians to assist victims of spouse abuse. Almost all (97%) physicians believe it is part of their role to assist victims of domestic violence. Almost one third (30%) hold victim-blaming attitudes toward victims of spouse abuse, and the majority (70%) do not believe that they have the resources available to them to assist victims of domestic violence. Being female, younger, practicing obstetrics-gynecology, and having fewer years in practice are all significantly related to holding supportive (positive) beliefs. The majority of negative beliefs held are about resource availability. Hence, training programs may need to be developed locally for physicians and tailored to individual community characteristics. Training programs should also emphasize the importance of understanding the victims of spouse abuse and of not blaming the victims for the violence.

Physician gender and women's preventive services.

OBJECTIVE: To determine whether the gender of women's regular physicians, controlling for physician specialty, is associated with women's receiving key preventive services within recommended intervals. DESIGN: Cross-sectional, nationally representative women's health telephone survey conducted by Louis Harris and Associates in February and March 1993 for The Commonwealth Fund. PARTICIPANTS: A total of 2,525 women in the continental United States, > or = 18 years old, including oversamples of African-American and Hispanic women. MAIN OUTCOME MEASURES: Receipt of each of five preventive services (blood pressure reading, Pap smear, cholesterol test, clinical breast examination, and mammogram) within specific periods. RESULTS: Physician gender makes a significant difference for two specialty areas and for three preventive services. Patients of women family or general practitioners are more likely than the patients of men to have received a Pap smear or a blood cholesterol test within the last 3 years, and the patients of women internists are more likely to have received a Pap test. Physician gender is associated with a higher likelihood of mammography, but this finding was limited to patients ages 40-49 of women family or general practitioners. Physician gender does not affect receipt of blood pressure screening or breast examination. CONCLUSIONS: Analyses reveal limited evidence that physician gender affects women's receipt of preventive services. Physician specialty appears to be a more powerful predictor of preventive services received. The limited evidence for a physician gender effect, however, is relevant for those women who rely on a family or general practitioner or an internist for regular care.

Comparison of contraceptive implant adopters and pill users in a family planning clinic in Baltimore.

All 133 women who began using the Norplant contraceptive implant between August and December of 1991 at a Planned Parenthood clinic in Baltimore were compared with a sample of 112 women who obtained prescriptions for the pill at the same clinic during the same time period. A multivariate analysis found that women of Medicaid are significantly more likely than those who are self-paying to select the implant rather than the pill. Similarly, compared with women who have had no children, those who have had two or more are also significantly more likely to choose the implant. However, adolescents and women who have had an abortion are no more likely than other women to select the implant.

PIP: Researchers compared data on 133 women, who began to use the contraceptive implant, Norplant, between August and December 1991, with data on 112 women, who received prescriptions for oral contraceptives (OCs) during the same time period, to examine how first-time Norplant acceptors differed from women choosing OCs. All the women attended a US Planned Parenthood clinic in Baltimore, Maryland. Clinic clients tended to be Black, low-income, and inner-city residents. Medicaid payment was the strongest determinant of using Norplant (95% vs. 32%; p .05; adjusted odds ratio [AOR] = 28.47). The influence of a family size of at least 2 children was the next strongest determinant (AOR = 3.78). The only significant predictor of choosing Norplant among Medicaid patients was number of children (AOR = 10 for 1 child, 20 for at least 2 children). Adolescents were no more likely to use Norplant than older women. Women who had experienced 1 or more abortions did not choose NOrplant at a higher rate than those who had not had an abortion, suggesting that wish to avoid unwanted pregnancies is not a motivating factor. Since the researchers did not speak to the women and collected the data from the patients' charts, they could not determine the women's attitudes and perceptions. All removals were Medicaid patients, indicating a need to determine whether Medicaid reimbursement encourages early removals or whether paying out-of-pocket for removal would be a disincentive to early removal. They recommended further research to determine who cost influences the choice of contraceptive among women with private health insurance. Another research topic should include adolescents' perceptions about Norplant, their knowledge of the 4-year time frame, and their desirability of early childbearing.