Listening to Parents: A National Survey of Parents With Young Children.
K.T. Young, et al. Ar-chives of Pediatrics & Adolescent Medicine 152 (March 1998): 255-62.

To better meet parents’ needs for information and support on child-rearing, pediatric practices should consider creative ways to reconstitute and augment their current services and systems of care.

This study consisted of a series of 25-minute, in-depth structured telephone interviews with a nationally representative sample of 2,017 parents living with children aged birth to 3 years. The sample included mothers and fathers who were biological parents, stepparents, or guardians. The mother or father was randomly selected to complete the interview.

Most parents feel that pediatric health care system meets the health needs of their children, but that clinicians often fail to discuss non-medical questions. Parents want more information and support on child-rearing: Seventy-nine percent reported that they could use more information in at least one of six areas of child rearing (such as discipline), and 53 percent wanted information in at least three areas. Forty-two percent had talked with their child’s physician about non-medical concerns. Such interventions can positively affect parental behavior. For example, breastfeeding and reading to the child on a daily basis were much more likely if a physician encouraged parents to do so. Changes in how pediatric care is practiced and in priorities of the routine visit may be required.

Ten-Year Risk of False Positive Screening Mammograms and Clinical Breast Examinations.
J.G. Elmore, et al. The New England Journal of Medicine 338 (April 16, 1998): 1089-96.

Techniques are needed to reduce the false positive rates of breast cancer screening and their associated psychological and economic costs. Until such techniques are implemented, health care providers should educate women about the risk of a false positive result of breast cancer screening. Also, health care providers should be trained to deal with positive results of breast cancer screening tests when they occur.

This 20-year retrospective cohort study involved 9,762 screening mammograms and 10,905 screening clinical breast examinations performed on 2,400 women aged 40 to 69 years old. Of the women screened, 23.8 percent had at least one false positive mammogram, 13.4 percent had at least one false positive breast examination, and 31.7 percent had at least one false positive result for either test. The risk of a false positive test increased with the number of breast cancer screening tests, so that by the time a woman had undergone 10 tests, the estimated cumulative risk of at least one false positive mammogram was just under 50 percent and the estimated cumulative risk of at least one false positive breast examination was about 22 percent. For every $100 spent for screening, an additional $33 was spent to evaluate the false positive tests.

Relationship of Functional Health Literacy to Patients’ Knowledge of Their Chronic Disease.
M.V. Williams, et al. Archives of Internal Medicine (26 January 1998): 166-72.

To improve health outcomes and patients’ understanding of their diseases, efforts are needed to use education techniques that increase comprehension among patients who are unable to understand written materials related to their ailments. These techniques include providing appropriately writ-ten materials, using oral communication, and improving visual presentation.

A sample consisting of 402 patients with hypertension and 114 patients with diabetes from hospitals in Atlanta, Georgia, and Torrance, California, were administered the Test of Functional Health Literacy in Adults (TOFHLA). Inadequate health literacy was evident in 49 percent of the patients with hypertension and 44 percent of the patients with diabetes. Twelve percent of the hypertension patients and 11 percent of the patients with diabetes had marginal health literacy, while the percentages for adequate health literacy were 39 per-cent and 45 percent respectively. The patients in this sample were given oral examinations to test their knowledge of their diseases. Strong correlations between health literacy and knowledge of disease were evident for both the hypertension and the diabetes patients. Only 66.8 percent of the hypertension patients with inadequate literacy levels (as opposed to 91.7 percent of those with adequate literacy levels) were able to identify the fact that blood pressure can be lowered through weight loss. These correlations remained consistent for diabetes patients despite prior attendance in diabetes education classes by 73 percent of the patients. The authors emphasize that, because of the constant monitoring and medicating that patients with these diseases must perform, education on the specifics of the disease is imperative.

Health Insurance and Access to Primary Care For Children.
P.W. Newacheck, et al. The New England Journal of Medicine 338 (February 19, 1998): 513-19.

Having health insurance predicts childrens’ access to and use of primary care.

This study analyzed the effects of health insurance coverage on childrens’ access to primary care, on the basis of a current and national representative sample of nearly 50,000 children from the 1993-1994 National Health Interview Survey (NHIS). Insured children were more likely to receive care in physicians’ offices, private clinics, or health maintenance organizations (87 per-cent vs. 76 percent for uninsured children). In contrast, uninsured children were more likely to receive their care in community and other health centers (18 percent vs. 6 percent for insured children) and in hospital emergency rooms. Children without health insurance coverage were six times as likely as insured children not to have a usual source of care (24 percent vs. 4 per-cent). Uninsured children were al-most twice as likely as insured children to have no identified regular physician or other medical provider at their usual site of care. In addition, families of uninsured children were about 40 percent more likely than families of insured children to report dissatisfaction with waiting times for appointments, the manner in which questions were answered by the practitioner, or the overall care received from their usual source of care.

The authors conclude that enactment of the State Children’s Health Insurance Program under the Balanced Budget Act of 1997 might improve access to and use of primary care by children, depending on whether and how it is implemented in each State.

Improving Preventive Health Care in a Medical Resident Practice.
L.J. Cardozo, et al. Archives of Internal Medicine 158 (February 9, 1998): 261-64.

Interventions to improve preventive health service (PHS) performance rates have a better chance of success if they are simple, practical, and inexpensive.

This study compared PHS compliance rates in a resident practice (RP) with those of a collaborative nurse practitioner practice (NP), both serving inner-city patients. A total of 132 patient charts in the NP group and 111 in the RP clinic were reviewed. Data collected included six PHSs, such as pelvic exams and stool testing. A significantly lower PHS performance rate was documented in the RP, and an intervention to improve this process of care was implemented. The intervention required that following every resident-patient encounter, the resident present the current status of the patient’s PHSs to the attending physician. In addition, as part of every clinic visit progress note, documentation of the patient’s PHS status was required in the assessment and treatment plans. Following the intervention period (1994-1995), 100 charts from the RP and 116 charts from the NP were selected and data on the performance of six PHSs were abstracted. The intervention resulted in improved PHS performance rates in the RP, to a level nearly equal to the NP. From a teaching perspective, methods that use reinforcement techniques have been shown to enhance knowledge, attitudes, and clinical practice skills.

Communicating with Patients Who Have Limited Literacy Skills. Report of the National Work Group on Literacy and Health.
The National Work Group on Literacy and Health. The Journal of Family Practice 46 (February 1998): 168-76.

Persons at all literacy levels have a better understanding of simple written materials compared with complex materials. The fifth grade readability level is an appropriate goal for most health care materials.

The average reading skill level of adult Americans is between grades 8 and 9, and the reading skills of Medicaid participants are at about the fifth grade level. Between 40 million and 44 million people (approximately one-quarter of the U.S. adult population) are at the lowest level of literacy, based on five functional levels developed by the 1993 National Adult Literacy Survey. These individuals have rudimentary literacy skills and are often unable to understand even basic written materials. For example, these persons would likely be unable to read and understand dosage, notes from their child’s teacher, poison warnings or bottle directions for household cleaners, or a newspaper.

Health Knowledge of Predominantly Mexican American High School Students.
B.A. Smith, et al. Journal of Health Education 29 (January/February 1998): 21-25.

Improved health education and instructional strategies designed to increase health knowledge for Mexican-American adolescents is needed.

This study of 237 predominantly Mexican-American high school students (106 males, 131 females) in social studies classes used the Health Knowledge Inventory/Alpha (multiple- choice) to determine the students’ knowledge in 11 health categories, such as accidents and safety, consumer health, physical fitness, and substance use/abuse. The overall test score for the students was 47.1 out of 110. The two items with the highest percentage of correct responses related to weight loss and mammograms.

In general, the adolescents studied had only limited knowledge students on several items, such as: barbiturates, when combined with alcohol, were the most for making informed lifestyle choices. There was a high percentage of incorrect responses by potentially lethal of the drugs listed (68.8 percent answered incorrectly); the obese are at higher risk for diabetes (65 percent answered incorrectly); and smoking during pregnancy increases risk of low birth weight babies (56.5 percent answered incorrectly). The authors recommend that high school curricula emphasize the health topics related to high-risk behavior of Mexican-American adolescents.

Health-Related Behaviors of Women Physicians vs Other Women in the United States.
Archives of Internal Medicine 158 (February 23, 1998): 342-48.

Women physicians’ health behaviors may provide useful standards for other women in the United States.

The results of the Women Physician’s Health Study (WPHS) and the 1992 Behavioral Risk Factor Surveillance System (BRFSS) survey were weighted specifically to oversample older female physicians. The sample was divided into three groups of women aged 30 to 70 years: female physicians (4,501 participants), women of average socioeconomic status (35,361 participants), and women of high socioeconomic status (1,316 participants). The groups were compared in terms of smoking prevalence and patterns, alcohol consumption habits, and other health and safety habits. Additional comparisons among the groups were made regarding participation in health screenings such as mammography and Pap testing.

Women physicians generally had more healthy behaviors than their nonphysician counterparts. For example, women physicians were more likely to have never smoked (77.7 percent), to eat fruits and vegetables, and to always or nearly always wear a seat belt (96.3 percent). In addition, women physicians underwent screening or testing more recently than women in the general BRFSS population, except for blood pressure, for which the numbers were equal.

Tobacco Industry Promotion of Cigarettes and Adolescent Smoking.
J.P. Pierce, et al. Journal of the American Medical Association 279 (February 18, 1998): 511-15.

To prevent addiction to smoking, it is necessary to understand the influences encouraging adolescents to begin smoking. Tobacco industry advertising and promotional activities can influence young people who never considered smoking to start.

This study evaluated the association between receptivity to tobacco advertising and promotional activities and progress in the uptake process, defined sequentially as: 1) never smokers who would not consider experimenting with smoking, 2) never smokers who would consider experimenting, 3) experimenters, and 4) established smokers. A group of 1,752 adolescents ages 12-17 who never smoked cigarettes and were not susceptible to smoking when first interviewed in 1993 were reinterviewed in 1996 to determine their susceptibility to smoking or experimenting. More than one-half named a favorite cigarette advertisement in 1993 with the Joe Camel advertisements the most popular.

Although having a favorite advertisement predicted which adolescents would progress by 1996, possession of or willingness to use a promotional item was even more strongly associated with future progression. Based on an attributable risk calculation, the authors estimate that 34 percent of all experimentation in California between 1993 and 1996 can be attributed to tobacco advertising and promotional activities. Nationally, this would be over 700,000 adolescents each year. This study focused on the influence of tobacco promotional activities on nonsusceptible never smokers. It is possible that these influences also encourage experimenters to continue smoking until they become addicted and act to prevent addicted adolescent smokers from quitting.

Impact of a High School Condom Availability Program on Sexual Attitudes and Behaviors.
M.A. Schuster, et al. Family Planning Perspectives 30 (March/April 1998): 67-72.

Condom availability programs appear not to have increased sexual activity among high school students and appear to have led to improved condom use among males.

This pretest-posttest evaluation study of a condom availability program in a Los Angeles County high school consisted of an anonymous, self-administered baseline survey of 1,945 students in grades 9 through 12. The surveys were administered before the condom program started and a followup survey of 1,112 students was conducted a year later. The two surveys obtained information about the students’ condom use, sexual behaviors, and knowledge, attitudes, and beliefs about sexually transmitted diseases, pregnancy, and contraception.

The percentage of males who reported using condoms every time they engaged in vaginal intercourse during the past year increased from 37 percent to 50 percent. The percentage of males who reported condom use at recently initiated first vaginal intercourse increased from 65 percent to 80 percent. Self-reported likelihood of using a condom for vaginal intercourse during the following year increased dramatically for those who had never had vaginal intercourse but did not change significantly for those who had had vaginal intercourse. Among those male and female students who had never had vaginal intercourse, the proportion of students who reported plans to use a condom at first intercourse increased from 62 percent to 90 percent among men and from 73 percent to 94 percent among women. Both before the program started and 1 year later, 10 to 13 percent of students said that they definitely would not have vaginal intercourse during the following year.

Suicide After Natural Disasters.
E.G. Krug, et al. The New England Journal of Medicine 338 (February 5, 1998): 373-78.

Providing social support and facilitating aid could help prevent suicide in victims of severe floods, hurricanes, and earthquakes.

This study reviewed data during the 36 months before and 48 months after events in 377 counties were declared Federal disasters between 1982 and 1989. The results show that suicide rates increase after severe floods, hurricanes, and earthquakes, with rates varying at different times. Overall, the suicide rate increased by 13.8 percent during the 4 years after a severe natural disaster. In the 4 years after floods, there was an increase of 13.8 percent; in the first 2 years after hurricanes, 31.0 percent; and in the first year after earthquakes, 62.9 per-cent. Increases in suicide rates were found for both sexes and for all age groups. The suicide rate increased 21.8 percent for men and 14.5 percent for women. The rate increased 24.9 percent in the 10-to-29 age group, 18.4 percent in the 30-to-59 age group, and 18.3 percent in the group 60 and older. Reasons for suicide after a natural disaster include loss of family members, friends, property, or jobs; long-lasting alterations of day-to-day life; and disruption of social networks. The authors recommend several specific prevention measures, including targeting disaster prone areas for programs that reduce the conditions that predispose people to commit suicide and preventing disasters through measures such as building flood walls and strengthening warning systems for hurricanes.

Children Who Prosper in Unfavorable Environments: The Relationship to Social Capital.
D.K. Runyan, et al. Pediatrics (January 1998): 12-18.

Those interested in the healthy development of children need to find new and creative ways to support interpersonal relationships and strengthen the communities where families carry out daily activities.

Participants in the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) were included in this study. The data from these five ongoing studies of the causes and effects of child abuse were obtained through similar methods, differing only in the sample selection criteria. The study examined 667 children between the ages of 2 and 5 years from Baltimore, San Diego, North Carolina, and Seattle. Children were defined as "at risk" for a number of reasons, such as having low birth weight, having teenage mothers, being placed in foster homes before the age of 3½, and "failing to thrive" by the age of 2. Social capital, the "benefits that accrue from social relationships in communities and families," was assessed through five factors: two-parent home, socially supported mother, no more than two children in the home, supportive neighborhood, and church attendance. The most prevalent indicator, neighborhood support, was found among 59 percent of the families of children doing well and 48 percent of other families. The least prevalent indicator, regular church attendance, was found in 37 percent of the entire sample. Only 16 percent of all study children reported the presence of at least four of the five indicators measured. Social capital emerged as an important predictor of child well-being after taking factors such as family income and site differences into account.

The Frequency and Correlates of Violent Behaviors in a Statewide Sample of High School Students.
Family & Community Health (Janu-ary 1998): 38-53.

Health professionals working to prevent violent and aggressive behavior among adolescents need to incorporate identified risk factors (e.g., drug and alcohol use) into assessment and intervention efforts.

A sample of 1,679 high school students (ages 14 and older) was surveyed from a variety of high schools in the South Carolina Youth Risk Behavior Survey. Correlations were determined between students of varying race (black or white) and gender and engagement in risky behaviors. The study revealed the following: substance abuse was correlated most highly with all of the violent behaviors surveyed; history of sexual intercourse was correlated strongly with nearly all of the violent behaviors surveyed; white males were more likely than any other group to carry weapons both on and off school property (50 percent and 26 percent, respectively); black males were more likely to force someone into having sexual intercourse (9 percent); black females and males were more likely to be victims of forced sexual inter-course than their white counterparts; a high percentage (39 percent) of the students who had forced someone into having sexual intercourse had been forced themselves.

The strongest, most consistent predictors of fighting were drug use and sexual activity. Infrequent attendance at religious meetings was correlated with increased likelihood of being in fights and, among female students, of carrying a weapon.

Community Characteristics Associated With Elevated Blood Lead Levels in Children.
B.P. Lanphear, et al. Pediatrics 101 (February 1998): 264-71.

Community characteristics can be used to develop screening strategies to identify children with elevated blood lead levels and increase efforts to identify houses with lead hazards before children are unduly exposed.

This study identified community characteristics associated with children having elevated blood lead levels (³10 mg/dL) and examined whether these characteristics can be used to identify such children. Data on 20,296 children were obtained from a countywide screening program in Monroe County, New York. Data for a sample of 1,144 children were re-viewed.

More than 95 percent of all the children with elevated blood lead levels lived in the city of Rochester. Only 4 percent of children who lived outside the city had elevated blood lead levels, compared with 37 percent of those who lived in the city. The mean blood level and the percent of children having a blood lead level of 10 mg/dL or higher increased as the percentage of the population that was black or Hispanic rose and as poverty increased. Increased crowding, older age of housing, and the screening rate also were associated with higher blood lead levels.

The authors conclude that community characteristics can be used to predict elevated blood lead levels and are useful to target testing and hazard control programs. In combination with lead standards for house dust, paint, and soil, this type of analysis should enable communities to identify lead hazards in high-risk neighbor-hoods before a child is poisoned or has undue lead exposure.

Incidence of Adverse Drug Reactions in Hospitalized Patients. A Meta-Analysis of Prospective Studies.
Lazarou, et al. Journal ofthe American Medical Association 279 (April 15, 1998) 1200-1205.

Because a large number of serious adverse drug reactions (ADRs) occur even when drugs are properly prescribed and administered, ADRs represent an important clinical issue.

To find the overall incidence of ADRs in hospitalized patients, a meta-analysis of data from 39 prospective studies from U.S. hospitals over a 32-year period combined the incidence of ADRs occurring while in the hospital with the incidence of ADRs causing hospital admission.

Serious ADRs were defined as an ADR that results in death, is permanently disabling, requires hospitalization, or prolongs hospitalization. In hospitalized patients the overall incidence of serious ADRs was 6.7 percent and of fatal ADRs, 0.32 percent.

Overall, in 1994, the authors estimated that 2,216,000 hospital patients experienced a serious ADR and that 106,000 deaths were caused by ADRs. Fatal ADRs appear to be between the fourth and sixth leading cause of death, and their incidence has remained stable over the last 30 years.

Universal Infant Hearing Screening by Automated Auditory Brainstem Response Measurement.
J.A. Mason and K.R. Herrmann. Pediatrics 101 (February 1998): 221-28.

Mild, moderate, and severe bilateral, persistent hearing loss can be identified in the nursery by automated auditory brainstem response measurement in order to provide amplification as needed before age 6 months and thus optimize speech and language development.

This study involved 10, 372 infants born during a 5-year period. Universal hearing screening by automated auditory brainstem response was done in the nursery. Infants who failed the screening test were followed up diagnostically. Successful screening in the nursery was achieved for 96 percent of infants. Hearing aids were recommended for those infants who had bilateral hearing loss. The incidence of bilateral loss requiring amplification was 1.4/1,000. The incidence of congenital bilateral hearing loss in the well population was 1/1,000 and in the neonatal intensive care unit population, 5/1,000. Amplification was recommended for 15 infants; well infants who used hearing aids before 6 months achieved age-appropriate speech and language development. The cost of screening was $17 per infant and the cost to identify each true bilateral hearing loss was $17,750.

The authors note that the cost of identifying infants’ hearing loss at birth was a fraction of the anticipated cost of providing educational and community services to people whose hearing loss is found later. The authors recommend a two-stage universal newborn screening protocol, amplification before age 6 months, and regular attendance of infants at hearing therapy sessions.

Molecular Amplification Assays to Detect Chlamydial Infections in Urine Specimens from High School Female Students and to Monitor the Persistence of Chlamydial DNA after Therapy.
C.A. Gaydos, et al. The Journal of Infectious Diseases 177 (February 1998): 417-24.

Use of urine amplification assays for sexually active adolescents has the potential to significantly improve the control of chlamydial infections. This study compared two types of urine amplification assays (polymerase chain reaction [PCR] and ligase chain reaction [LCR]) for the diagnosis of Chlamydia trachomatis infections. Urine specimens from 408 high school female students were tested. Sixty-four patients were confirmed as infected. After therapy, urine specimens were tested to determine persistence of Chlamydia trachomatis DNA in urine. At 1 to 3 days after therapy, PCR and LCR were positive for 40 percent and 73.3 percent of patients, respectively. The percentage of positive results declined over time; none of the specimens collected 16 to 21 days after therapy and more than 21 days after therapy were positive.

Because chlamydial infections are highly prevalent in young adolescents and most are asymptomatic, active screening is strongly recommended by the Centers for Disease Control and Prevention. The authors believe urine amplification assays are cost-effective and can be used frequently throughout the adolescent years, when adolescents are at high risk of infection.