Women who receive home visits from nurses while pregnant and during the first two years after their child is born continue to benefit from these visits through their child's 15th birthday. They have fewer subsequent pregnancies and wait longer to have their next birth than those who do not receive such services; they also are less likely to neglect or abuse their children, to be dependent on welfare or to engage in criminal behavior. These findings, from a longitudinal study in Elmira, New York,1 are largely confirmed by early results of a program in Memphis.2
The Elmira Study
The original Elmira study, conducted in 1978-1980, included patients obtaining free prenatal care from a clinic sponsored by the county health department and private doctors' offices. Women were recruited for the study if they were less than 25 weeks pregnant, had had no previous live births and were either younger than 19, unmarried or of low socioeconomic status (defined as living in a household whose head received public assistance or worked in an unskilled or semiskilled occupation). The sample consisted of 400 women, of whom 48% were younger than 19, 62% were unmarried and 59% were of low socioeconomic status; 11% were black.
Patients were randomly assigned to one of four treatment groups: One group received sensory and developmental screening for their children, along with referrals for treatment as needed; another received these services as well as free transportation for prenatal and well-child care. The third group received screening and transportation as well as visits from a nurse during the prenatal period, and the fourth group received all of these services, plus continued nurse visits until the children were two years old. The visiting nurses addressed health issues during pregnancy and early childhood; parenting skills; and planning for the future, especially in the areas of family planning, education and work. They made an average of nine prenatal visits and 23 postnatal visits per family.
Of the 400 original study participants, 324 were available for follow-up when their children were 15 years old. The investigators interviewed the women and their children and consulted records from state agencies to learn about the mothers' childbearing, use of public assistance, employment, substance abuse and criminal behavior since their first birth, as well as any history of child abuse and neglect. For the purposes of the analysis, the two groups that had not received nurse visits were combined, and their experiences were compared with those of women who had received visits through their child's second birthday, on the assumption that the greatest effect would be seen among women visited during both the prenatal and the postnatal periods. The researchers conducted separate analyses for the overall sample and for the 130 unmarried women of low socioeconomic status.
In the sample as a whole, women who had received nurse visits did not differ from those in the comparison group with respect to their pregnancy history and reliance on welfare in the 15 years after their first birth. Among unmarried women of low socioeconomic status, however, several statistically significant differences emerged. Women who had received nurse visits had significantly fewer subsequent pregnancies than those who had not (an average of 1.5 vs. 2.2), fewer live births (1.1 vs. 1.6) and a longer average interval between first and second births (64.8 months vs. 37.3 months). They also averaged fewer months receiving Aid to Families with Dependent Children (60.4 vs. 90.3) and relying on food stamps (46.7 vs. 83.5). Levels of Medicaid enrollment and length of employment did not differ according to whether the women had had home nursing visits.
Unmarried women of low socioeconomic status who received nurse visits were significantly less likely than those in the comparison group to be arrested for or convicted of a crime, to have problems with alcohol or drugs, or to abuse or neglect their children. A significant but weaker association was found between nurse visits and reduced child abuse for the sample as a whole.
The Memphis Study
While the investigators were encouraged by the results of the Elmira study, they questioned whether the findings applied to other populations--especially low-income, urban black women. This led to a trial in Memphis of a similar program administered by the public health department. The sample included 1,139 clinic patients who obtained obstetric care in 1990-1991. The women were predominantly black (92%), unmarried (98%) and younger than 19 (64%); most had household incomes at or below the federal poverty level (85%).
Though women visited by nurses did not differ from those not visited in their use of prenatal and emergency obstetric services, they were more likely to use other community services and to be employed; the association with employment was especially strong among those enrolled in school. Overall, women who received visits had fewer yeast infections and lower rates of pregnancy-induced hypertension than other women. Even among women who had hypertension during pregnancy, the program had a positive effect: Those visited by nurses had significantly lower blood pressure at delivery than members of the comparison group.
No association was found between nurse visits and infant's birth weight or Apgar score, length of gestation or rate of preterm delivery. However, mothers who received nurse visits were more likely than others to attempt breastfeeding (26% vs. 16%). By the child's second birthday, visited women were less likely than those in the comparison group to have become pregnant again (36% vs. 47%). They also were less likely to have given birth (22% vs. 31%), but this difference was significant only among those with a high level of psychological resources (a measure reflecting intelligence, mental health and self-efficacy).
While the two groups did not differ significantly with regard to education or employment, women who had received visits relied slightly less on Aid to Families with Dependent Children. Moreover, these women had homes rated as significantly more conducive to child development than did the women in the comparison group, and they were less likely to believe in punishment, lack empathy and have unrealistic expectations for infants--attitudes that may be associated with abusive behavior. This was borne out by the finding that children who had nurse visits were less likely than others to require health care for injuries that could have resulted from abuse.
In reviewing their findings, the investigators note that in the Elmira study, the program impact was most marked among women who were unmarried and poor, and in the Memphis study, the program's effects on the children's injuries and the mothers' caregiving skills were most
notable among women with few psychological resources. Thus, the researchers conclude, the visiting nurses had the largest impact on those who needed them most: women whose resources and intellect were the most limited and who were under the greatest stress. They add that the Memphis program may have greater effects (for instance, on levels of education, employment and use of public assistance) after more time has elapsed.
The researchers caution that their results should not be interpreted to mean that all programs involving home visits from nurses will have similar effects. They note, "While some other types of home-visitation programs have shown some promise, most have failed." Nevertheless, they conclude that "as health and social welfare policy is redesigned ... it makes sense to begin with programs that have been tested, replicated, and found to work."--M.L. O'Connor
1. Olds DL et al., Long-term effects of home visitation on maternal life course and child abuse and neglect: fifteen-year follow-up of a randomized trial, Journal of the American Medical Association, 1997, 278(8):637-643.
2. Kitzman H et al., Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing: a randomized controlled trial, Journal of the American Medical Association, 1997, 278(8):644-652.
Making condoms available in high schools does not increase teenage rates of sexual activity, but does result in higher rates of condom use among sexually active students, according to a study of nearly 13,000 public high school students in New York City and Chicago.1 Sexually active students in New York--where condoms are made available to public high school students--were significantly more likely to have used a condom during their most recent act of intercourse than were sexually active students in Chicago, who do not have the same access to condoms.
Data were collected in 1994 from 7,119 students from 12 randomly selected New York public high schools and 5,738 students from 10 Chicago public high schools. New York was chosen for the study because its Board of Education implemented one of the first school condom distribution programs in 1991. Chicago was chosen because it has a large, unified urban school system similar to New York's: Its public schools are ethnically diverse, have a high dropout rate and provide students with education about HIV and AIDS, but not condoms.
Participants were students in grades 9-12 attending required classes. They completed self-administered questionnaires designed to measure their knowledge, attitudes and behavior related to sexual activity, condom use and HIV prevention. The researchers categorized students who had been in a New York or Chicago public high school for less than one year as "new students." Because these students had not attended their schools for a significant period of time, they probably did not participate in their schools' HIV and AIDS education programs and were used as a proxy baseline measure. The study categorized students who had been enrolled in a New York or Chicago public high school for one year or more as "continuing students."
Nearly 72% of students in both the New York and the Chicago samples were 15-17 years old, 18% were younger and 10% were older. Girls represented 54% of participants in New York and 53% in Chicago. Some 47% of respondents were black, while about 28% were Hispanic, 7% were Asian, 17% were white and fewer than 1% were Native American.
In both cities, 47% of new students and 60% of continuing students were sexually active, and predictably, sexual activity increased with age. Sexually active students in both cities were similar with respect to levels of different kinds of intercourse (vaginal, oral and anal sex), age at first intercourse and age of first partner. One-quarter of sexually active new students and one-fifth of sexually active continuing students in each city said they had had three or more partners in the previous six months.
However, sexually active continuing New York students reported a significantly higher rate of condom use in their last sexual encounter than did their counterparts in Chicago (61% vs. 56%). New students in New York and Chicago were about equally likely to report using condoms during their last intercourse (58% and 60%, respectively).
The researchers used logistic regression techniques to explore the factors influencing the likelihood of condom use at last intercourse among continuing students, controlling for a range of potentially confounding variables, including age, gender, race or ethnicity, number of partners and frequency of intercourse. The results indicated that continuing students in New York were significantly more likely than their Chicago counterparts to have used a condom at last intercourse (odds ratio, 1.4).
For high-risk students--those who reported having had three or more sexual partners in the past six months--the differential by city was even more pronounced. High-risk participants in New York were almost twice as likely as those in Chicago to have used a condom at last intercourse (odds ratio, 1.9). Furthermore, while fewer than 20% of New York's sexually active students said they had received a condom from school, high-risk students said they had done so in significantly higher proportions than low-risk students. A logistic analysis examining factors affecting the odds of sexual activity revealed no difference between continuing students in New York and Chicago. Nor did additional analysis yield significant results for a variety of subgroups and dependent variables.
The researchers concede that having no measurement of condom use among New York high school students before the condom availability program had begun was a major methodological limitation of the study. Nevertheless, they conclude, their findings illustrate that high school condom distribution programs can decrease urban teenagers' risk of contracting HIV and other sexually transmitted diseases. School-based condom availability does not increase rates of adolescent sexual activity, as many opponents of public high school condom distribution argue, but does have a modest although significant effect on condom use.
"Thus, the fear that making condoms available will increase sexual activity, a primary political obstacle to making condoms available to high school students, appears to be unfounded," the investigators note. School-based condom availability, they add, is a "low-cost, harmless addition" to high school HIV and AIDS prevention education that deserves policy consideration.--M. Raab
1. Guttmacher S et al., Condom availability in New York City public high schools: relationships to condom use and sexual behavior, American Journal of Public Health, 1997, 87(9):1427-1433.
|Table 1. Estimated savings associated with each use of emergency contraception prescribed after unprotected intercourse, by provider setting and method, assuming that births are either averted or delayed
|Setting and method
|Copper T IUD
|Copper T IUD
|*Includes the full cost of all unintended births. ÝAssumes that 69% of unintended births are mistimed and would occur two years later.
Emergency treatment with either combined oral contraceptives or progestin-only minipills is cost-effective in preventing pregnancy in women who have had unprotected sexual intercourse. Savings are realized whether the pills are obtained in a managed care or public-payer setting, but are greater under managed care. Another method, the Copper T IUD, is not cost-effective when used only for emergency contraception. These are several of the findings of a study examining the medical costs of emergency contraception available in the United States.1
Emergency treatment with combined pills is delivered in a dose of 100-120 mcg of ethinyl estradiol and 0.5-0.6 mg of levonorgestrel within 72 hours of unprotected sexual intercourse, and an identical dose 12 hours later. For the minipill, the recommended dose is 0.75 mg of levonorgestrel given within 48 hours of unprotected intercourse and again 12 hours later. The Copper T IUD can be used for emergency contraception if it is inserted within seven days of unprotected intercourse. If left in place, the device provides effective contraception for up to 10 years. It should not be used, however, by women at risk for sexually transmitted diseases.
On the basis of published reports from clinical trials, the researchers assumed that 19 of every 1,000 women treated with combined pills or minipills will become pregnant, compared with 72 of every 1,000 untreated women, for a 74% reduction in the pregnancy rate. Insertion of a Copper T IUD within seven days of unprotected intercourse was assumed to reduce the risk of pregnancy by more than 99%.
The investigators considered two ways of delivering emergency contraceptive pills: During a routine visit to a clinician, women who use barrier methods of contraception, withdrawal or periodic abstinence can be given a supply of emergency contraceptive pills to have on hand in the event that they have unprotected intercourse. Alternatively, women can obtain the method during a visit to a clinician after unprotected intercourse.
Medical costs were examined in two provider settings, private managed care and publicly funded programs. Data on costs under managed care were obtained from the Medstat Systems Market-Scan database, which reflects the 1991 costs of large employers in 45 major metropolitan areas. Estimates for public-payer costs were based on 1993 fee schedules and statistics for Medi-Cal, the California Medicaid program.
In one set of analyses, the investigators assumed that all unintended pregnancies are unwanted and that none of the births averted by emergency contraception would ever occur. However, since an estimated 69% of unintended pregnancies are mistimed rather than unwanted, the researchers also conducted analyses in which they assumed that the use of emergency contraception would simply delay these births by two years.
Costs and Savings
The average medical cost of various outcomes of an unintended pregnancy (ectopic pregnancy, birth, spontaneous abortion or induced abortion) totals $3,795 under managed care and $1,680 in a publicly funded program. Assuming that some births are simply delayed, the average cost per unintended pregnancy totals $1,653 under managed care and $779 in a public-payer setting.
Assuming that births averted by emergency contraception would never occur, each use of combined pills results in savings of $142 under managed care and $54 in a public-payer system (Table 1). Minipills also are cost-effective, saving $119 under managed care and $29 in publicly funded programs. If most births are delayed rather than avoided, combined pills remain cost-effective regardless of provider setting; minipills result in a small savings only under managed care. The Copper T IUD is not cost-effective when inserted for emergency contraception and then removed, but it becomes cost-effective if it remains in place for as little as four months.
If women receive an advance supply of emergency contraceptive pills from managed care providers and use the method whenever it is required, annual savings (assuming that births would be averted rather than delayed) range from $263 for couples relying on male condoms to $498 for couples relying on female condoms. In a public-payer system, the savings range from $99 to $205. Savings decrease if the pills are not used every time that they are required; they also are lower if most births are delayed.
According to the investigators, their estimates understate cost savings because they reflect several conservative assumptions: that an office visit is always required for the provision of emergency oral contraception; that an entire pack of combined pills or two full packs of minipills are prescribed in an emergency; that managed care providers pay average wholesale prices for oral contraceptives and IUDs; that use of emergency contraceptive pills after unprotected sexual intercourse prevents only 74% of pregnancies that otherwise would have occurred; and that delayed births are postponed only two years.
Furthermore, the investigators note that emergency contraceptive pills would result in even greater savings if appropriate doses of combined oral contraceptives and minipills were packaged and labeled for this purpose, as in the United Kingdom and other countries. The availability of emergency contraception could be enhanced, the researchers add, if pharmaceutical manufacturers sought Food and Drug Administration approval of the method, if clinicians routinely informed women about the availability of emergency contraception before the need arises and if insurers provided broader contraceptive coverage.--P. Marsteller
1. Trussell J et al., Preventing unintended pregnancy: the cost-effectiveness of three methods of emergency contraception, American Journal of Public Health, 1997, 87(6):932-937.
Many street youth engage in activities, including injection-drug use, unprotected intercourse and sex with multiple partners, that put them in danger of contracting HIV. Young women may be particularly vulnerable because they are more likely than young men to be sexually active and are less likely to use condoms; youth without stable housing also are at particularly high risk because they are more likely than those in stable housing to use drugs. These are the principal findings of a study conducted during 1993 in four northern California cities.1
The study--believed by the investigators to be the first to use street-based sampling exclusively--was part of the AIDS Evaluation of Street Outreach Projects, which focuses on hard-to-reach high-risk populations. Participants were recruited from places where homeless and runaway youth tend to congregate, such as parks, street corners, outdoor food lines and bus stations; they were paid $20 to complete interviews lasting 30-40 minutes. Young people were eligible for the study if they were without stable housing (i.e., lived on the street or in abandoned buildings, cars, parks or shelters); were housed but had been without stable housing repeatedly during the past year; or were integrated into the street economy (i.e., lived off the proceeds of drug dealing, stealing, panhandling, prostitution or posing for or selling pornography).
Of the 429 participants, 77% were white, 68% male and 85% heterosexual; their mean age was 19.2 years. Seventy-five percent were without stable housing, 23% had housing but had been homeless within the last year, and the remaining 2% were housed but were part of the street economy. Ten percent reported that they had exchanged sex for food, drugs or money to live on. Women were, on average, younger than men (18.3 vs. 19.6 years) and were more likely to say they were gay or bisexual (24% vs. 11%), to have been tested for HIV (65% vs. 55%) and to have had a sexually transmitted disease (28% vs. 16%).
In the first part of the analysis, the investigators explored rates of drug use among the youth interviewed and used logistic regression techniques to identify factors associated with recent use of injection drugs (i.e., use within the previous 30 days). Next, they examined risky sexual behavior and conducted regression analyses to identify factors associated with condom use during participants' most recent intercourse.
Drug use was common among the youth in the sample. Some 70-95% reported ever having used LSD, marijuana, alcohol, cocaine or speed, and 42-53% said they had used ecstasy, heroin or crack cocaine. In all, 32% had ever used injection drugs, and 47% of these had used such drugs recently. Among recent users, 65% had shared needles or syringes in the past 30 days (though 72% of this group said they had used bleach to clean them).
The results of the regression analysis indicated that youth who were older than 18 or who were involved in drug dealing, prostitution or theft were twice as likely to have used injection drugs in the previous 30 days as were their counterparts who were younger and not involved in these activities (odds ratios, 1.9-2.0). The odds of recent injection-drug use were higher among those who used alcohol daily (2.5) and rose further among youth who did not have stable housing (3.7).
Turning to sexual behavior, the analysts found that 61% of the young people had been sexually active in the past 30 days; of these, most had engaged in vaginal sex (98%) or oral sex (71%). Among youth who had recently had vaginal sex, 52% had been with a primary partner only, 40% had been with other partners only and 8% reported sex with both primary and other partners. (A primary partner was defined as "a main or steady partner, or someone who is important or special.") Women were significantly more likely than men to have had a recent sexual encounter (76% vs. 55%) and to have had sex with a primary partner only (66% vs. 43%).
Rates of condom use were low. Twenty-three percent of all those who had had vaginal sex in the prior 30 days had used a condom every time, and 43% had used a condom at last intercourse; 31% reported that they intended to use a condom during every sexual encounter in the next six months. Young women were significantly less likely than young men to use a condom every time they had intercourse (14% vs. 29%) and to plan to use condoms for the next six months (22% vs. 38%).
The low level of condom use apparently is not attributable to unavailability of the method. Sixty-six percent of those sampled had obtained condoms in the past month, 55% said they usually carried condoms and 31% had a condom with them at the time of the interview. These measures of condom availability did not vary between men and women, but youth in unstable housing situations were more likely than those who were housed to have received condoms recently and to have one with them at the time of the interview.
The researchers examined a number of attitudinal variables regarding risk-taking and condom use. While 62% of participants said they worry about getting HIV and 59% considered it likely that they would contract the virus, only 27% believed that their behavior puts them at risk of infection. Most (67%) said their friends accept the practice of safer sex, though only 14% thought their friends always use condoms. Forty-eight percent reported having generally good experience with condoms. Young women were significantly more likely than young men to worry about getting HIV (74% vs. 56%) and to believe that their friends accept safer sex (74% vs. 53%).
Findings from the regression analysis revealed that the likelihood of condom use at most recent intercourse was influenced by different factors for women and men. The odds were substantially elevated among women who had had sex with a nonprimary partner (3.0) and who had had good experience with condoms (4.0); they declined somewhat among women who lacked stable housing (0.3). Availability of condoms was not a significant factor for young women. For men, by contrast, the likelihood of condom use was raised among those who usually carried condoms (4.6), those who had obtained condoms in the last month (3.9) and those who believed their peers accept safer sex practices (2.6); young men who used marijuana daily had a reduced likelihood of condom use (0.4).
According to the researchers, their findings have a number of implications for street outreach and prevention programs. Noting that the current focus of such programs is on increasing the availability of condoms and other prevention materials, they suggest that while this approach can be effective for young men, it should be coupled with efforts to increase condom acceptability among females. Furthermore, in view of the finding that regular marijuana use reduces young men's likelihood of using condoms, the researchers recommend that prevention efforts be directed at alcohol and drug use as well as at sexual behavior. Young women, for whom condom availability does not appear to be an important factor, present a different challenge; for them, programs need to "encourage condom use with primary as well as other sexual partners, and promote the positive experiences one can have using condoms," according to the investigators.
The investigators point out that since their research did not use population-based probability sampling, it is not clear how well the results apply to youth in other areas. However, they believe the implications of their findings are clear: If outreach workers are going to influence behavior change, "new gender-specific approaches for encouraging both sexual and drug using risk reduction are greatly needed."--M.L. O'Connor
1. Clements K et al., A risk profile of street youth in northern California: implications for gender-specific human immunodeficiency virus prevention, Journal of Adolescent Health, 1997, 20(5):343-353, 1997.
Only 10% of Missouri mothers surveyed had received all seven types of prenatal health advice recommended by the Public Health Service, and those who had not received the full range of advice had an increased risk of bearing a very low birth weight infant. These are the main findings of an analysis of data from the Missouri Maternal and Infant Health Survey, which included 2,205 women who gave birth between December 1989 and March 1991.1
In 1989, the Public Health Service recommended that pregnant women receive health behavior advice in the following areas: breastfeeding; reducing or eliminating alcohol consumption; reducing or eliminating smoking; not using illegal drugs; maintaining a proper diet; using vitamin or mineral supplements; and gaining an appropriate amount of weight during pregnancy. Data from the Missouri survey permit analysis of the frequency with which women receive these types of advice and the association between types of advice received and birth weight.
Survey participants were identified through Missouri's birth and fetal death certificate database. Only those who had had a singleton live birth and who had received prenatal care were included in this analysis. The sample included 692 women who had delivered an infant with a very low birth weight (less than 1,500 g), 742 who had an infant with a moderately low birth weight (1,500-2,499 g) and 771 who had borne a baby with a normal birth weight (2,500 g or more).
About half of the women (53%) were in their 20s; the rest were about evenly divided between those younger than 20 (24%) and those aged 30 or older (23%). The majority were white and married (61-62%), had 12 or more years of schooling (69%) and had worked during their pregnancy (62%). Almost half participated in Medicaid or the Special Supplemental Food Program for Women, Infants and Children (46-48%). Thirty-three percent said they had smoked during pregnancy, and 39% had had a prior adverse birth outcome (preterm birth, low-birth-weight infant or fetal death).
The respondents were most likely to have been advised regarding diet and nutrition. In all, 94% said that their prenatal care provider had talked to them about the use of a vitamin or mineral pill during pregnancy, 62% had been counseled about how much weight to gain and 55% had received instruction about how to improve their diet.
Fifty-four percent of all mothers reported receiving advice to cut back on or discontinue smoking. Among the 973 women who reported smoking during the year prior to pregnancy, 86% said they had been advised to cut down or quit. A total of 718 women had smoked during pregnancy; 92% of these mothers had been counseled to reduce or eliminate smoking.
In all, 47% of respondents reported being told not to use illegal drugs; 39% said that their provider had recommended that they stop or cut down on drinking. Among the 487 mothers who reported drinking alcohol during the first trimester, 56% said that they had been advised against this.
Of the seven recommended types of advice, breastfeeding was the least often addressed. Only 38% of respondents had been encouraged to consider breastfeeding.
Overall, 10% of the women had received all seven types of advice; this proportion did not vary by birth-weight category. Using logistic regression techniques, the analysts explored the effects of not having received all of the recommended advice on birth weight. When other factors that may contribute to low birth weight were accounted for, women who had not received the full range of advice were 1.5 times as likely to have delivered very low birth weight infants as they were to have delivered normal-birth-weight infants. Comparisons involving mothers of moderately low birth weight infants revealed no statistically significant differences.
According to the researchers, the finding that failure to receive the complete range of prenatal health behavior advice was associated with very low birth weight but not with moderately low birth weight was somewhat surprising, because several areas addressed by the Public Health Service recommendations (inadequate weight gain, smoking, alcohol use and cocaine use) are more closely linked to moderately low birth weight than to very low birth weight. One possible explanation for the effect of not having received the full range of advice on very low birth weight, the researchers suggest, is that women who were most likely to recall receiving advice also had been more likely to choose providers who offered comprehensive counseling and to follow their advice. Nevertheless, they contend, the implication that health education and behavioral advice may help prevent very low birth weight is important, since prenatal care tends to focus on medical risk factors.
The investigators commend providers' nearly universal efforts to advise pregnant women against smoking, but note that results in other areas point to a need for routine and timely advice. For instance, they suggest that many women may not have received information about breastfeeding because they delivered preterm and their provider was planning to address this issue later in their pregnancy. However, according to the researchers, "if breastfeeding advice is offered early in pregnancy, a woman may have time to consider the benefits and examine any misgivings that she may harbor."
In conclusion, the analysts note, prenatal education may play an important role in preventing low birth weight. However, they add, information about the way in which prenatal advice is provided to and received by women will be necessary to clarify its effectiveness in influencing women's health behavior.--I. Olenick
1. Sable MR and Herman AA, The relationship between health behavior advice and low birth weight, Public Health Reports, 1997, 112(4):332-339.
Adolescents are more willing to disclose sensitive information on topics such as sexuality, substance abuse and mental health to physicians who give assurances of confidentiality than to doctors who give them no such assurances, according to findings from a randomized controlled trial.1 Furthermore, adolescents are more likely to say they would return to a physician who gave them an unconditional assurance of confidentiality than to one who mentioned exceptions.
The sample consisted of 290 male and 272 female students attending a required class on social issues at three California high schools in 1994-1995. Each participant selected a coded audiotape player containing a recording of one of three scripted scenarios reflecting how a physician may conduct a routine office visit with an adolescent patient. In one version, before posing questions about sensitive topics, the physician gave an assurance of unconditional confidentiality; in one, the physician gave an assurance of confidentiality with exceptions for suicidal tendencies and suspected abuse; and in one, the physician said nothing about confidentiality.
Male and female students chose tape players from separate boxes containing equal numbers of tapes with each scenario and with male and female physicians. After listening to the recording, participants filled out a questionnaire that asked about their demographic characteristics, their past experiences with physicians, their willingness to disclose general and sensitive information to the physician on the tape, the likelihood that they would give truthful answers if questioned by this physician and the likelihood that they would return to this physician if they had a particular problem.
On average, the participants were 14.9 years old, and most were in ninth grade (62%); the remainder were in grade 10 (32%) or grade 11 (6%). White students made up most of the sample (77%); Asian, black and Hispanic students each accounted for 3-4% of the group, and students of other races or ethnicities constituted the remaining 11%. Most of the participants were of middle or high socioeconomic status, as determined by their mother's level of schooling. Some 62% had been to a physician for a routine physical examination in the past year, and 97% had seen a physician at least once in the past two years. The groups listening to each version of the tape did not differ significantly in their social and demographic characteristics or past experiences with physicians.
Among the 540 respondents who answered questions about their last routine visit to a physician, 33-41% reported that the physician had asked if they drank alcohol, had sex or smoked cigarettes; 15-25% reported being asked if they had suicidal thoughts, needed condoms or were depressed. Between 59% and 78% of respondents whose physicians had asked them about smoking, suicide, sexual activity or the need for condoms said that they had answered the question completely honestly; fewer than half said that they had been completely honest about drinking alcohol or about feelings of depression (48% and 36%, respectively).
Seventeen percent of all respondents reported having avoided medical care in the past for fear of parental discovery. In addition, 7% said that in medical visits they had made as teenagers, the physician had spoken with their parents about information the respondents had not wanted them to know about.
Results of an analysis of variance revealed that both male and female respondents who had listened to a tape with a female physician were significantly more likely than those who had heard a male physician to say they would be willing to disclose general and sensitive information to that doctor, to answer questions honestly and to make a return visit. Regardless of which version of the tape participants heard, similar proportions of males and females said they would be willing to reveal sensitive information and make a return visit to a doctor of their sex. However, whereas female adolescents' willingness declined if the doctor was a man, male adolescents' willingness increased if the doctor was a woman. (These trends were not statistically significant.) The analysis also showed that respondents of higher socioeconomic status were more likely than those of lower socioeconomic status to reveal general information to a physician.
To isolate the effects of confidentiality assurances on adolescents' willingness to disclose information and return for future visits, the investigators conducted a linear regression analysis controlling for physician sex and, in the general disclosure category, for respondents' socioeconomic status. Significant differences were detected between the groups that had heard confidentiality assurances and the group that had not: On average, 47% of the respondents who had received an assurance of confidentiality reported willingness to reveal sensitive information, compared with 39% of the group to whom confidentiality had not been mentioned. The proportion did not differ significantly between those who had heard an unconditional guarantee of confidentiality and those who had heard that the physician would make certain exceptions.
The likelihood of future visits differed significantly across the three groups. Among respondents who had heard any assurances of confidentiality, 67% said they would be willing to make a future visit to the same physician, compared with 53% among those who had heard no such assurances. Furthermore, those who had heard unconditional guarantees were significantly more likely than those who had received conditional assurance to be willing to make future visits (72% vs. 62%). There were no significant differences in willingness to disclose sensitive information between the group that heard an unconditional assurance and the group that heard a conditional guarantee.
Confidentiality guarantees showed no effect on willingness to disclose general information or on intended honesty. In each group, 16-30% of adolescents inaccurately recalled whether the physician on the tape had mentioned confidentiality, and 6-12% inaccurately recalled whether a conditional guarantee had been mentioned. An analysis excluding these respondents showed increased willingness to disclose general information in groups with confidentiality assurances and greater strength in the effects on disclosure of sensitive information and intention to make return visits.
The researchers suggest that physicians consistently discuss confidentiality with their adolescent patients, not only to obtain more accurate answers to risk-assessment questions, but also to encourage visits from adolescents with privacy concerns who might otherwise avoid care. The investigators call for further research on the effect of confidentiality assurances on adolescents at high risk for sensitive health problems and studies to clarify and ameliorate the potential negative impact of conditional assurances on adolescent patients' willingness to return for future visits.--M. Breslin
1. Ford CA et al., Influence of physician confidentiality assurances on adolescents' willingness to disclose information and seek future health care, Journal of the American Medical Association, 1997, 278(12):1029-1034.
© copyright 1998, The Alan Guttmacher Institute.