Social and Structural Influences on Multiracial Identification and Health: a Public Health Mandate to Precisely Measure, Theorize, and Better Understand Multiracial Populations.

There is a growing group of adolescents and young adults in the USA who identify as multiracial. However, very little research, especially health research, focuses on understanding multiracial identification and health and behavioral outcomes for multiracial populations in comparison to their single-race counterparts. Understanding the intersectional influences on this identification process is critical to updating the literature on racial and ethnic identity and health with more accurate identifications and categories. It is especially critical that there is an explicit focus on understanding the impact of structural racism and discrimination when studying the process of racial identification and the impact on health. This review takes an interdisciplinary approach relying on a review of multiple research literatures: the historical literature on race, racism and categorization, psychological and adolescent medicine literatures on adolescent development, the sociological literature on racial and ethnic identification, and the limited public health research beginning to disentangle multiracial health outcomes. An empirically testable conceptual framework is offered to frame the organization of this review-demonstrating the multiple spheres of influence on racial and ethnic identification and the implication for health outcomes.

The impact of fertility intentions on behavior: the case of sterilization.

In this paper, we take a new approach to the question of whether or not intentions regarding future fertility affect fertility-related behavior. Our approach has three principal features: 1) it takes sterilization as its outcome, rather than pregnancy or birth; 2) it is based on a conceptual model in which fertility-related behavior is seen as determined by a long-range planning process, modified by unanticipated life course contingencies; and 3) it uses data on desired total family size. Using data from the National Survey of Families and Households, we find that achieving one's desired parity has a strong, persistent, and positive effect on the probability of sterilization, supporting our view of the long-term nature of fertility intentions. People do modify their behavior in the face of unanticipated contingencies, but those effects are unexpectedly small.

Social movements as catalysts for policy change: the case of smoking and guns.

Social movements organized around perceived threats to health play an important role in American life as advocates for change in health policies and health behaviors. This article employs a framework drawn from social movement and related sociological theories to compare two such movements: the smoking/tobacco control movement and the gun control movement. A major purpose of the article is to identify specific social movement ideologies and actions that are more or less likely to facilitate achievement of the movement's health policy objectives. The article concludes that the success of health-related social movements is associated with (1) the articulation of a socially (as well as scientifically) credible threat to the public's health, (2) the ability to mobilize a diverse organizational constituency, and (3) the convergence of political opportunities with target vulnerabilities.

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.

Dysmenorrhea and use of oral contraceptives in adolescent women attending a family planning clinic.

OBJECTIVES: This study examined the prevalance of dysmenorrhea in female adolescents and the effect of experiencing a reduction in dysmenorrhea on oral contraceptive use. STUDY DESIGN: This was a prospective panel study in which 308 adolescent women at an inner-city family planning clinic were interviewed about their experiences with dysmenorrhea and their oral contraceptive use at three points in time over a 6-month period. A chi 2 test and multiple logistic regression analysis were done. RESULTS: The overall prevalence of dysmenorrhea in this population was 79.6%; 18.2% reported severe dysmenorrhea. Those who had severe dysmenorrhea and also experienced the reduction of dysmenorrhea as a result of oral contraceptives were eight times more likely to be consistent oral contraceptive users (p less than or equal to 0.02). CONCLUSIONS: It is important to screen female adolescents for dysmenorrhea, provide them with information about the beneficial side effects of oral contraceptives, and follow up these young women to make sure they are experiencing the alleviation of their symptoms.

PIP: The prevalence of dysmenorrhea in female adolescents and the effect of experiencing a reduction in dysmenorrhea on oral contraceptive (OC) use were examined. This was a prospective panel study in which 308 adolescent women at an inner city family planning clinic were interviewed about their experiences with dysmenorrhea and their OC use at 3 points in time over a 6-month period. A chi square test and multiple logistic regression analysis were done. The overall prevalence of dysmenorrhea in this population was 79.6%; 18.2% reported severe dysmenorrhea. Those who had severe dysmenorrhea and also experienced a reduction in dysmenorrhea as a result of OC use were 8 times more likely to be consistent OC users (p or= .02). It is important to screen female adolescents for dysmenorrhea, provide them with information about the beneficial side effects of OCs, and follow up these young women to be certain that their symptoms are being alleviated.

Adolescent women's contraceptive decision making.

A modified rational decision model incorporating salient events and social influences (particularly from sexual partners) is used to analyze adolescent women's consistent use of oral contraceptives (OCs) over a six-month period. Data are taken from a panel study of 308 clients of an inner-city family planning clinic. Expected OC use was computed for each subject on the basis of subjective expected utility (SEU) theory, and is found in multivariate analyses to be a significant predictor of actual OC use. In addition, variables representing baseline and follow-up partner influences, the salience of pregnancy for the subject, and positive side effects of OCs during the first months of use are found to predict OC use. Partner's support of OC use during follow-up and positive side effects of OCs are found to predict OC use among subjects for whom OC use was not the expected decision according to baseline SEU. Implications of the findings for models of adolescents' contraceptive behavior and for clinicians are discussed.

PIP: Adolescent women's contraception decision making is studied from the perspective of modified decision making theory, specifically subjective expected utility (SEU) theory. It is assumed that individuals choose contraceptive use on the basis of perceived costs and benefits, susceptibility (risk), and severity of outcomes. A comparison is made the SEUs of using versus not using contraception where the decision may be a rational one. There is a discussion of how this study is different from other SEU studies. The study population included 430 OC users, who were 18 years and not pregnant, at a Planned Parenthood Clinic in Baltimore City in 1988 and interviewed at 3 and t months after their OC visit. 89% of the baseline population completed both followup interviews. Attrition was due to inability to locate respondents. The analysis pertained to 308 respondents who had at least 1 act of coitus in the followup period. Respondents were primarily inner city and sexually active with a high risk of teen pregnancy. Consistency of OC use is the dependent variable, and expected OC use is a key independent variable if the subject is a rational decision maker. Other independent variables were the selection of who were influential members of her household, the number of stability of sexual relationships, having an older sex partner, and having a sex partner supportive of her consistent OC use. Other than partner changes, the frequency of intercourse and side effects of OC use, and the age, race, and mother's education were included. The multiple repression analysis revealed that for those subjects with the expected choice in SEU terms of OC use were 1.59 times more likely to use OCs consistently than those for whom OC use was not expected. SEU concepts were helpful in predicting consistency of OC use in a 6 month period, and intervening events and social influences affect OC use in predictable ways. Inconsistent contraceptors and partners who were older, nonsupportive of birth control, or unstable or nonexclusive. Partners may have more influence than conventionally accepted. Breakups increased the odds of consistent use, but not frequency of intercourse. Having had an abortion is a significant predictor of OC use. The implications are that adolescents are capable of rational decision making and could be advised of the risk factors for consistent use. The limitations are that clinic clients may be self selected on the level of partner support, may not be representative of all seeking contraceptive services, and did not receive the current AIDs prevention and condom recommendations. Future research might use the SEU model with a non-OC method, other outcomes such as STD or abortion prevention, further refinement of the partner's SEU, and the framework in which OC use is promoted over other methods as the clinic effect

Consistency of condom use for disease prevention among adolescent users of oral contraceptives.

A six-month prospective study examined consistency of condom use for disease prevention among 308 adolescent women who had received a prescription for oral contraceptives at a family planning clinic. Only 16 percent used condoms consistently over a six-month period, yet 30 percent were considered at high risk for sexually transmitted diseases (STDs) because of multiple, sequential or concurrent relationships with male partners. The type of relationship in which the adolescents were involved did not predict consistency of condom use. Consistent condom use was associated with having asked a partner to use a condom, perceiving partner support for condom use, having less frequent sexual intercourse and using oral contraceptives inconsistently. The findings suggest that family planning providers need to more strongly emphasize to adolescents the importance of consistent condom use to protect against STD infection.

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.

Components of change in adolescent fertility, 1971-1979.

This article disaggregates change in adolescent fertility between 1971 and 1979 into four components: change in marriage patterns, in nonmarital sex, in pregnancy, and in birth. It also assesses quantitatively the relative contribution of each component to the change over time in two fertility outcomes: the probability of a nonmarital live birth and, given a live birth, the odds of its being nonmarital. The changes in the probability of sexual debut prior to marriage and in marriage patterns themselves are the two most important contributors to these changes. The influence on the change in adolescent fertility outcomes of the decreased likelihood of marriage following a nonmarital pregnancy was compensated for by the increased use of abortion to terminate the pregnancy.

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.

Women in the labor force: are sex mortality differentials changing?

The relationship between the increasing participation of women in the labor force, female mortality, and the male-female mortality differential is examined in this work. The mortality experience of women and men 16 to 64 years of age in the Wisconsin civilian labor force is examined for the period 1974 to 1978 through comparisons of central death rates and sex mortality ratios. In general, this study suggests that, at this time, female mortality is not negatively affected by female labor force participation. Furthermore, there is little evidence to suggest that the entrance of women into the labor force will narrow the sex mortality differential in the general population. However, among certain occupation groups, males and females of similar marital status experience mortality rates that are quite similar. Possible interpretations of these unusual findings are presented.

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.

Professional satisfaction and client outcomes. A comparative organizational analysis.

In studies of the effectiveness of health care organizations, the job satisfaction level of professional staff is often viewed as an "outcome," since providing a climate that satisfies participants' needs is one aspect of organizational effectiveness. Staff satisfaction, however, has not been linked with outcomes associated with clients. In this article, the authors examine the relationship between the aggregate job satisfaction level of nursing staff in 77 family planning clinics and two client outcomes: the aggregate satisfaction level of teenage clients with contraceptive services obtained in the clinic, and the subsequent rate of client compliance with contraceptive prescriptions. Among the variables studied in testing an organizational-level model, it is found that the job satisfaction level of nursing staff is the strongest determinant of the aggregate satisfaction level of clients; client satisfaction level, in turn, predicts the rate of clients' subsequent contraceptive compliance. Staff satisfaction has a noteworthy indirect effect on compliance through client satisfaction. Compliance, however, appears to be more susceptible to variations in clinic structure than to variations in staff satisfaction levels. Implications of these findings for studies of effectiveness of health services and for management of health care organizations are discussed.

Female labor force participation and female mortality in Wisconsin 1974-1978.

The following research question is addressed in the study: what effect will the entrance of women into the labor force have on female mortality rates for all causes of death combined as well as specific causes relating to occupational stress, behavioral factors and physical hazards associated with occupation? This question is examined through comparisons of age, marital status and occupation-specific death rates for all causes of death combined and for selected causes of death. Death certificates provided by the Wisconsin Bureau of Health Statistics for the years 1974-1978 and population data provided by the 1976 Survey of Income and Education were used to construct death rates. The death rates of the white civilian female population of Wisconsin 16-64 years of age were examined using exploratory data analysis techniques (schematic plots and median polish) and standard errors. In general, the death rates of women in the labor force are substantially lower than those of housewives. These results may indicate that the role of housewife exposes women to health hazards. In addition, the results of this study may suggest some selectivity of healthy women into the labor force or a protective effect of labor force participation. In a limited number of instances, labor force participants' mortality rates exceed those of housewives. In the 60-64 year old population, white-collar workers, specifically, sales workers, managers and professionals, experience significantly higher death rates than housewives. In addition, specific groups of labor force participants experience significantly higher death rates than housewives for accidental deaths (i.e. laborers 16-44 and 45-54), deaths due to heart disease (i.e. laborers 45-54 and sales workers 60-64) and deaths due to malignant neoplasms (i.e. white-collar workers 60-64 years of age). The possibility that these instances indicate the direction of future mortality trends should be considered.

The influence of client-provider relationships on teenage women's subsequent use of contraception.

This paper describes the relationships of selected dimensions of nurse-client interaction in county health department family planning clinics to the subsequent contraceptive use of the clinic's unmarried teenage clients. The subjects for the study are the clients and professional staff of 78 clinics: 2,900 eligible clients making their first contraceptive visit and 338 clinic staff nurses. Results of interviews demonstrate that client and staff expectations and interactions are significant predictors of adherence to a contraceptive regimen; under circumstances where clients anticipate, and staff employ, authoritative guidance in helping the clients to select a contraceptive method, clinic mean levels of contraceptive use are substantially increased. Overall, 40 per cent of clinic variation in contraceptive compliance is explained by the interaction dimensions and other aspects of clinic organization addressed in this paper. Implications of these results for the structuring of family planning clinic programs directed toward teenage women are briefly considered.

Sex differences in mortality.

"Patterns of sex differences in mortality in developed and developing countries are briefly described, and the range of explanatory approaches that have been used to account for these differences are reviewed. Attention is primarily focused on the higher male than female mortality rate in developed countries. Biological and behavioral/environmental perspectives on these differences are considered in some detail. It is concluded that a specifically sociological approach to sex differences in mortality requires both greater attention to the spectrum of variation within and across societies and a more complex model of causality that takes account of gender differences in the nature of mortality risks."

Aging and the family.

Characteristics of family and household structure are examined in this paper to shed light on an important aspect of the life conditions of older persons in countries at different levels of development. Using various measures, both direct and indirect, the analysis showed the existence of a nuclear household as a predominant family form. Extended household families are more common in Asian countries, especially India, than in other regions for which data are available. While available cross-national data do not enable us to assess the extent to which older persons reside in households with their children, headship rates indicate that the majority of male older persons continue to maintain their position as heads of households in later life and that female headship increases with age. This is confirmed by analysis of data on marital status, which show higher proportions of males currently married than for females and sharply higher widowhood levels for females. Marriage at older ages seems to be relatively low. A general trend within most developed countries is toward increasing independent living, especially for females, and a sharp decline in both males and females living in a household with relatives.

Professional norms, personal attitudes, and medical practice: the case of abortion.

PIP: The structural conditions under which obstetricians personally opposed to abortion will provide abortion services were examined. The data were obtained during the winter of 1975-1976 as part of a survey of abortion practices among private obstetricians in Maryland. Of the 473 physicians identified as eligible for inclusion in this study, 443 completed a telephone interview, and 318 of those interviewed returned a mail questionnaire. It was hypothesized that personally conservative obstetricians would provide abortion services if these services were supported by prevailing professional norms, whereas personally liberal obstetricians would provide these services irrespective of prevailing professional norms. The data strongly supported the hypotheses. Uniformly, conservative obstetricians were more likely to perform abortions and to demonstrate high levels of commitment to abortion services if they were in a favorable, in contrast to an unfavorable, normative climate. Of 6 comparisons between the abortion activities of conservative obstetricians in conservative versus liberal environments, 4 were significant at greater than the .05 level, all in the direction of greater activity in the more liberal climate. In contrast, the liberal obstetricians were more resistant to the potentially modifying effects on their behavior of an opposing normative climate (as was predicted). With only 1 exception (number of abortions), obstetricians with attitudes favorable to abortion appeared to resolve conflict between their own attitudes and prevailing norms in favor of the former, choosing to provide, rather than to withhold, abortion services. The data suggest that attitudes, as well as religious beliefs, have their greatest effects on the initial decision to perform abortions.^ieng