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Managing the risk of suicide in acute psychiatric inpatients: A clinical judgement analysis of staff predictions of imminent suicide risk

noreply@blogger.com (Landrogek) — Mon, 25 Feb 2008 18:32:00 +0000

Abstract
Background: Predicting suicide risk in psychiatric in-patients in order to inform risk management decisions is compromised by the poor predictive validity of the available models.
Aims: This study explored the factors influencing judgements regarding suicide risk in psychiatrists and nurses working in acute psychiatric in-patient units in Scotland.
Method: Clinical judgement analysis. Information used by 12 psychiatrists and 52 nurses to make judgements about suicide risk were analysed over 130 hypothetical cases. Correlations and linear regression analysis were used to examine judgement consistency and information use.
Results: There was agreement between clinicians on the relative but not absolute degree of risk of each patient case. Consistency of judgments was low, particularly amongst nurses. All clinicians rated those with more previous suicide attempts, men, those with shorter admission times, and those who were less compliant and not improving clinically as at greater risk of suicide. Conclusions: Clinicians use cues that have been associated with suicide in traditional predictive models based on epidemiological studies and short term factors that may be particularly relevant to acute psychiatric settings. The inconsistencies observed can be interpreted to cast doubt on the validity of predictions of risk for imminent suicide and the role of such predictions in the assessment process.

Introduction
Psychiatric in-patients are at significantly increased risk of completing suicide in comparison
to the general population in all countries reflecting admission criteria (Eagles et al., 2001;
Powell et al., 2000). Preventing such suicides occurring is therefore a legitimate concern in
acute psychiatric care settings (National Confidential Inquiry, 2006) Despite criticisms of
the current practice in the area suicide risk assessments continue to be a mainstay of such
efforts and predictions of suicide risk are used to inform decisions that are potentially critical
to patient safety such as the level of observation/engagement ordered (National Confidential
Inquiry, 2006).
Clinicians working in acute psychiatric in-patient environment are tasked with assessing
who may be at increased risk of imminently completing suicide over periods of hours, rather
than months. However, the existing models of proven predictive validity are based on large
scale community samples and identify factors that are predictors for suicide over the ‘‘longterm’’
and at a group level. They are unable to accurately predict which individual patients
will commit suicide over the short term (Cassells et al., 2005; Hughes, 1995). In the absence
of tools with proven predictive validity how clinicians use the information available to them
in order to make suicide risk judgements and whether or not a consensus exists between
practitioners over who is at a higher risk are therefore important questions which, are
addressed in this study.
Clinicians are rarely able to accurately describe the clinical information they use
when making decisions (Denig et al., 2002; Harries et al., 2000). Clinical judgement
analysis is a research method that examines the relationship between an individual’s
judgement and the information they use to make that judgement (Harries et al., 1996).
Using linear regression techniques it identifies the relative weight or importance
individuals attach to different information items, without relying on potentially unreliable
self-reports. These ‘‘captured’’ judgement policies can then be compared between
individuals to identify areas of agreement or disagreement (Harries et al., 1996). The
approach has been used successfully within medicine to explore how clinicians use
information to inform their diagnosis of heart failure (Skane´r et al., 2000), and to explain
variation in practice for prescribing decisions (Backlund et al., 2000; Harries et al.,
1996).
This article present the results of a study which used clinical judgement analysis to
explore the factors influencing judgements regarding suicide risk of a group of clinicians
working in acute psychiatric in-patients in Scotland. The study examined the information
cues that clinicians used to inform their judgements of suicide risk, comparing them to
risk factors identified by a review of the literature (Cassells et al., 2005). The study also
considered the reliability of clinicians’ predictions. This study formed part of a larger
study examining the relationship between predictions of suicide risk and decisions
regarding observation/engagement whose results are not reported here and are the focus
of a further paper in preparation. Ethical approval for this study was granted by Lothian
MREC.
Method
The information used by clinicians to make risk judgements was analysed over a series of
hypothetical patient cases. The cases were presented in written form in a booklet.
Hypothetical cases are useful in this context for several reasons. First, it allows us to
study a complex judgement process, associated with a relatively rare outcome, easily.
Second, the correlation between cues across cases can be minimised in order to allow for
identification of the influence of individual cues on each person’s risk of suicide
judgements. Third, it allows for a subset of cases to be repeated within the booklet to
measure the consistency of judgements. Finally, it also allows for direct comparison
between clinicians, and clear measurement of agreement as all clinicians see the same set
of cases.
Participants
All psychiatrists and registered mental health nurses involved in the assessment of suicide
risk in acute psychiatric in-patient settings, in four Primary Care Trusts in Scotland were
invited to take part in the study.
Procedure
On agreeing to take part, participants were sent a data collection booklet, consisting of a
questionnaire and the judgement task. The questionnaire was designed to collect
demographic data on participants, together with details of the environment where they
worked.
The Judgment task
The judgement task consisted of a set of 130 hypothetical cases (scenarios), each defined in
terms of 13 pieces of information, plus 15 cases that had been picked at random and
repeated. An example of a case is shown in Figure 1. Each booklet consisted of the same set
of cases, presented in the same order.
For each case, participants were asked to judge how likely it was that the patient described
in the scenario would try to commit suicide within the next 24 hours. They indicated this on
a 10 cm bar (see bottom of Figure 1) anchored on the left with ‘‘no risk’’ and on the right
with ‘‘very high risk’’. Their judgement of likelihood on this bar was encoded as a rating
between 0 (no risk) and 100 (very high risk). They were also asked to state what observation
level they thought the patient should have as an intervention (on pass, general observation,
constant observation, special observation). These observation levels were those in use in the
majority of Scottish services at the time of the study (Table I) (Scottish Executive, 2002).
Participants returned the completed booklet to the researchers in a prepaid envelope. Only
data from fully completed and returned booklets was analysed.
Case profile
The 13 different potential predictors of successful suicide attempts in acute psychiatric inpatient
populations identified by (Cassells et al., 2005) were used as a basis for the cases.
These factors were a mixture of more traditional ‘‘long term’’ predictors (e.g., psychiatric
diagnosis, previous self harm) and more short term predictors (e.g., changes in clinical state,
comorbid drug or alcohol use).
For each of these predictors, a number of different potential levels of severity related to
suicide risk were developed (Table II). For each of the predictors, at each level, a number of
verbal descriptions were constructed and validated by a panel of experts. The descriptors
were developed following interviews with experienced clinicians. A computer program
(written in visual basic 6 by CH and adapted by DD, based on the cue generation program
used in (Evans et al., 1995), was then used to randomly generate a number of series of 130
scenarios. For each predictor, each level had an equal probability of being included in each
scenario. These sets of scenarios was sampled and re-sampled until, for each set that was
generated, the inter cue correlation was negligible.
To ensure that the final sample of 130 scenarios used in the study had face and content
validity they were selected from those scenarios that represented real in-patient cases with a
distribution designed to mimic the overall in-patient caseload. Scenarios were examined for
face validity by a panel of 4 experts (operationally defined as experienced psychiatrist/mental
health nurse practitioners). Participants were aware that no observation level had been
decided in these cases. Scenarios that did not represent a realistic acute in patient case were
discarded. Caseload distribution was determined via a local survey of the range and
prevalence of diagnoses within in-patient services together with an examination of national
statistics. The final number of scenarios used in the study was based on a ‘‘rule of thumb’’
suggesting that between 5 – 10 scenarios are necessary for every item of information used, to
ensure sufficient variety in the judgements that are made, and to provide stable statistical
estimates of cue weights (Cooksey, 1996; Harries & Harries, 2001).
Analysis
All data were analysed using SPSS (version 12.0). Clinicians’ judgements of likelihood that a
patient would attempt suicide within the next 24 hours, rated as a mark on a bar were
encoded as a rating between 0 (no risk) and 100 (very high risk). To examine the extent to
which clinicians agreed on the relative degree of risk for each case (i.e., if they identified the
same case as being at a higher or lower risk), Pearson’s correlations between risk judgements
by each pair of clinicians was calculated for each of the participants, and the mean
correlation was calculated via Fisher’s z transformation (Fisher, 1921). Agreement between
clinicians’ judgements’ of risk across all cases was measured using Kendall’s W measure of
concordance. Kendall’s W varies from 0 (no agreement) through to 1 (perfect agreement).
(Howell, 1992, pp. 280 – 282).
The reliability of clinician’s risk judgements were also examined by calculating
Spearman’s rho correlation on the two sets of judgments for the 15 cases that were
repeated within the vignette booklet. These 15 and their original equivalents form a test and
retest set of cases. The mean for nurses and for psychiatrists was calculated separately via
Fisher’s z transformation and an independent samples t-test of the mean difference was
used. Finally, an individual’s judgements of risk across the 130 cases were standardized and
regressed onto standardized cue values giving a set of standardized regression coefficients
(their judgement policy). These indicate how the participant used each item of information
to judge suicide risk. Mean differences in the beta-weights attached to information use were
analysed using independent sample t-tests.
Results
Participant characteristics
Twenty eight psychiatrists and 92 nurses consented to take part in the study (from a
potential pool of 88 psychiatrists/269 nurses) with 12 psychiatrists and 51 nurses returning a
completed booklet (53%). The mean age of participating psychiatrists was 39 years (SD 7.9;
range 25 – 53), 50% were male and 50% female. The mean age of participating nurses was
40 years (SD 8; range 20 – 54), 40% were male and 60% female.
Agreement between judgements of suicide risk
There was considerable variation in both psychiatrists’ and nurses’ absolute ratings of the
suicide risk for each individual vignette. On average the range between the lowest and highest
ratings for a vignette was 61.3 for psychiatrists and 78.4 for nurses. The range was over 75 in
15/130 (11.5%) cases judged by psychiatrists, and 79/130 (60.8%) cases judged by nurses.
The extent to which clinicians agreed in terms of the relative degree of risk was calculated by
examining the extent to which their judgements for the vignettes correlated with each other
(a significant correlation would indicate that they agreed on cases that were at greater/lesser
risk than others). The correlation of judgements for each clinician across all 130 cases was
compared to all other clinicians, giving a total of 3294 comparisons. Of these 3060 (92.9%)
were significantly positively correlated (p5.01). Agreement ranged from an r=0.018 to
r=0.733, with a mean correlation of 0.416. Agreement between psychiatrists was slightly
greater (98.5% of comparisons significantly positively correlated, mean correlation 0.486)
than agreement between nurses (92.9% of comparisons significantly positively correlated,
mean correlation 0.412).
Concordance between clinicians was assessed using Kendall’s W. The greatest agreement
was between the psychiatrists (W=.5, n=12), with agreement between the nurses slightly
lower (W=.41, n¼51). Concordance when comparing the judgements of the whole
clinician group was also lower (W=.41, n=63).
Reliability of risk judgements
Of the 12 psychiatrists, 7 (58%) had significant (p5.01) correlations between their risk
predictions on their test and retest cases (mean correlation 0.614, range .158 – .737). Of the
51 nurses 11 (22%) had significant correlations (p5.01) between their risk assessments
(mean correlation 0.479, range 0.024 – 0.844). An independent samples t-test of the mean
difference in Fishers z transformations of consistencies indicated that psychiatrists showed
greater reliability in their judgements than nurses did (t(61)=72.053, n=63, p5.05).
Factors influencing risk judgements
Individual judgement policies, which examined how each clinician used information to
reach their judgement of suicide risk, were calculated. The number of significant cues in a
judgement policy that predicted risk judgements varied between clinicians, ranging from 1
to 6. The average number of cues for both psychiatrists and nurses was 3.7, with a median
of 4. There was substantial variation in the fits of the linear regression models (R2)
between participants. The mean adjusted R2 for psychiatrists was 0.34 (median=0.34,
range .22 – .51) and for nurses 0.28 (median 0.29, range .04 – .51).
There was also some variation in the way clinicians were influenced by cues. Mean
standardized beta-weights for each of the cues for psychiatrists and nurses can be seen in
Figure 2.
Figure 3 indicates the percentage of clinicians who had a particular cue as a significant
predictor within their judgement policy, together with the direction of the weighting.
Both psychiatrists and nurses associated suicidal ideation with increased suicide risk,
although psychiatrists were significantly more influenced by this cue (t(61)=2.103,
n=63, p5.05). Psychiatrists were also significantly more influenced by the patient’s
diagnosis than nurses were (t(61)=5.387, n¼63, p=1.0). The number of previous
suicide attempts, being male, lack of clinical improvement, lack of compliance and
shorter admission times were also associated with higher risk of suicide judgments by
both groups of clinicians.
Three of the cues (insight, adverse events and protective factors) were not significant
predictors at all in psychiatrists’ judgement policies. Two cues (co-morbidity and insight)
were not significant predictors in nurses’ judgement policies. Suicidal ideation and previous
suicide attempts were important factors for the majority of psychiatrists and nurses. For 50%
of the psychiatrists, but only 8% of nurses, diagnosis was also an important predictor.
Clinical improvement, length of admission, gender, compliance and hopelessness were
important predictors for between approximately 20% and 40% of clinicians.
Discussion
Clinicians who took part in this study rated the patient cases represented in the scenarios at
varying degrees of risk, often with very large differences in ratings. A patient case therefore
could have likelihood ratings of completing suicide from one practitioner of 25 and from
another of 100. However, when comparing the relative degrees of risk, there appeared to be
consensus regarding cases that were of relatively higher risk, compared to others. Therefore,
although individual clinicians may have different anchor points on a scale related to what
they consider high or low risk to be, they did appear to agree on who was at higher risk
compared to another patient.
What is perhaps of more concern are the results of the analysis of the reliability of
clinicians risk judgements, across the 15 repeated patient cases. Overall psychiatrists were
more likely to provide roughly similar risk assessments for the same case at two different
time points, than nurses. However, for a significant proportion of psychiatrists (42%) and
the majority of nurses (78%), risk judgements across the same patient case at two different
time points were significantly different. This implies that the predicted risk of suicide in the
same patient, exhibiting the same symptoms and behaviour, seen at two different times by
the same clinician could vary substantially. However, low reliability, agreement and
accuracy is also associated with greater uncertainty in the decision task (Harvey, 1995).
These findings may reflect the inherent complexity associated with the prediction of suicide
in this population. An increased familiarity with the task is however, associated with
increased consistency and given the pre-eminent role ascribed to psychiatrists in the decision
making process in most settings this may explain the greater reliability observed in
psychiatrists’ judgements of risk (Shanteau et al., 2003).
Clinical judgement analysis is a method that examines the relationship between the
judgements’ that individuals make and the information they use to make them. The analysis
of judgement policies of clinicians that took part in this study highlighted variation in the
number of information cues clinicians use to inform their judgements of suicide risk, and
some variation in which cues are used according to professional group.
The psychiatrists in our sample were more likely to use the patients’ diagnosis as a
predictor of the likelihood of suicide than nurses, and appeared to place more significance
or weight on the presence of suicidal ideation as a predictor than nurses. However, what is
evident is the extent to which there is considerable agreement between the two groups on
the relative significance of other factors such as previous suicide attempts, gender, length
of admission, clinical improvement, compliance and hopelessness when assessing suicide
risk. Predictive models derived from epidemiological studies suggest that factors such as
suicidal ideation, previous suicide attempts, diagnosis, gender and length of admission are
long term predictors of successful suicide (Cassells et al., 2005) all of which appear as
factors used by clinicians in this study to inform their risk judgements. However,
clinicians’ judgement policies also included other factors, such as clinical improvement,
and compliance when making such risk judgements. These factors, along with others such
as the degree of insight a patient has into their condition, comorbid substance abuse and
social factors (such as the level of social support an individual receives) (Cassells et al.,
2005) have been identified as dynamic or short term factors linked to increased suicide
risk in psychiatric in-patients. It is still uncertain whether using these more short term
factors increases the accuracy of suicide risk predictions within acute psychiatric inpatients.
It is also unclear whether some short term factors are more significant than
others either generally of for individuals when trying to estimate suicide risk. Clinicians’
use of clinical improvement and compliance as predictors of risk within their judgement
policies imply that these factors may have more clinical utility than other short term
factors. However, whether they are more useful in terms of accurate prediction remains
uncertain.
One of the main methodological issues that needs to be considered when examining
the results of studies that use case vignettes is the transferability of subjects performance
from the judgement task simulated in the vignette to their performance in real task
situations. A number of studies have indicated that clinicians performance on ‘‘paper
cases’’ in clinical judgement analysis studies appears to be no different to that on ‘real
patients (Braspenning & Sergeant, 1994; Denig & Rethans, 1996; Kirwan et al., 1983).
In order to increase the transferability, the case vignettes constructed for this study
were based on both evidence from the research literature on key information that is
deemed to be associated with suicide risk in psychiatric in-patients, and expert validity.
However, it should be recognized that clinicians’ information use was limited to that
presented in the case vignettes. Individuals judgements in reality may be influenced by
elements of the task situation such as the context of the ward environment and resource
issues (such as staff availability), which, were not represented in the vignettes used within
this study.
One way to increase the validity of the judgement task that is carried out is to either base
the case vignettes on real patient cases (Skane´r et al., 1998), or to ask clinicians to carry out
judgements in the clinical setting and analyse the patient case retrospectively. Although
these approaches would overcome the limitations of presenting clinicians with paper-based
vignettes, they would also make it harder to control the information that clinicians receive,
or to directly compare clinicians’ judgments and policies. The combination of risk factors
identified and used in this study would probably rarely be recorded in totality for each
in-patient, and often a combination of a number of risk factors together in one
patient case is rare (Powell et al., 2000). If patients are used in clinical practice, then the
ability of comparing clinicians across the same cases for consistency is also lost.
A further issue that should also be acknowledged when considering the results of this
study is the nature of how risk assessments are made in clinical environments. This study
examined the judgements of individual practitioners when studies have highlighted that
this is often a process involving members of the multidisciplinary team (Bowers et al.,
2000).
The prediction of the likelihood of suicide forms one element of the broader process of
risk assessment and management of suicide risk that in turn forms part of the overall care of
the patient. Prediction of suicide risk is however in and of itself a complex task, evidenced by
the difficulties in producing models in those studies that have attempted to identify risk
factors. The importance of clinicians’ judgements is therefore paramount, as they need to
continually evaluate a variety of different information sources to reach a judgement about an
individual patient. Although there were some differences in how psychiatrists and nurses
used and weighted information regarding patients diagnosis and suicidal ideation to inform
their judgements in this study, overall there was remarkable agreement in the relative use
and weighting of information.
Within acute psychiatric in-patient areas, patients who are judged as being at higher
risk of suicide are often identified as requiring intensive support by means of higher
levels of observation/engagement (Bowers et al., 2000). The relationship between risk
assessments and decisions regarding interventions is therefore potentially critical. It has
been suggested that there is a relationship between risk assessments and the level of
observation a patient is placed upon (Kettles et al., 2004). However, research in other
areas has suggested that a clinicians judgements may not necessarily influence their
treatment decisions with the nature of the relationship between judgements reached and
decisions made varying between clinicians (Poses et al., 1995; Sorum et al., 2002).
Despite the relative agreement with which clinicians in this study identified patients they
considered to be at higher or lower risk, relative to other patients, this may not
necessarily lead to agreement regarding the interventions those patients receive. The
relationship between the risk judgements made by the clinicians in this study and their
subsequent decisions regarding observation level are however the subject of a further
paper currently in preparation.
Overall, psychiatrists and nurses appear to agree on the characteristics of patients who are
considered to be at higher or lower risk of suicide, within acute psychiatric in-patient
environments. They use a mixture of both long term predictive factors and more dynamic
short term factors, to inform these judgements. There are some discrepancies in the
importance that different professional groups attach to the patients diagnosis and level of
suicidal ideation, when making judgements. However, it has been possible from this study to
provide some transparency as to the way in which clinicians use different predictive factors
to inform their judgements regarding imminent suicide risk in acute psychiatric in-patients,
an area under explored to date. The inconsistency in risk judgments observed is significant
and must cast some doubt on the validity of using predictive models based on aggregated
risk factors.
Alternative approaches to risk management focused not on statistical models but rather
the lived experiences of service users may though offer scope for improved patient outcomes
in this area. Such improvements may lie however not in any improved accuracy in the
prediction of suicide risk but instead in terms of a decreased likelihood of suicide both
during and after the in-patient episode. A phenomenological perspective on suicide suggests
that we must seek to understand individuals’ unique reasons for suicide and not committing
suicide at a particular point in time. Central to this perspective is the belief that suicide is an
endpoint in a trajectory following high levels of societal, intra and interpersonal stress which
result in unendurable psychological pain described, compellingly by Shneidman (1993a) as
‘‘psychache’’. In the context of such unbearable distress suicide becomes a compelling and
even attractive means of escape. Risk factors such as suicidal attempts and suicidal thoughts
are expressions of distress which can exist independently or co-exist with underlying
pathology. An understanding of the sources of stress, particularly at an individual level is
therefore necessary because it is the individuals idiosyncratically understood psychological
anguish which is the driving force behind suicide and not simply an aggregated collection of
risk factors (Shneidman, 1993b). Adopting a phenomenological model of suicide prevention
seeks therefore to ascertain in partnership with the service user their reasons for living and
dying (Jobes, 2000, p. 11). These reasons, revisited regularly, form the basis of a care plan
which focuses not on the treatment of the disorder but on addressing explicitly these issues
which the patient gives for wishing to kill themselves as treatment priorities, whilst
maintaining and expanding on the reasons for the patient’s ambiguity about suicide (i.e.,
their reasons for not committing suicide). Practice is focused on changing the balance in
favour of living with suicide seen not as a symptom of a mental illness which can be
addressed via treatment of the supposedly underlying disorder but simply as a coping
strategy ‘‘albeit a limited and problematic one’’ (Jobes, 2000, p. 11). The challenge for
clinicians in such circumstances becomes not how to assess risk accurately but instead how
to engage constructively with the service user in order to enable them to want, and be able,
to ‘‘say yes to life’’ (Degan, 1996, cited by Barker, 2003, p. 97) not just in hospital but after
discharge.
The presence of a collection of risk factors whether static, e.g., diagnosis, history of
previous attempts or more dynamic such a recent history of substance misuse or the loss of a
significant relationship may tell us that the individual falls into a particular risk category. It
cannot reliably predict the choices that individual will make in the short term regarding
suicide. Engaging with the individual patient and their lived experience of that world on an
ongoing basis may however allow us to understand why for some patients at some times
suicide can come to seem their only option. Only by doing so can we then begin to explore
with the patient what they feel might need to change in order for them to decide to choose
life over death.
Conclusion
One interpretation of one of the findings of this study in terms of the inconsistent judgement
by clinicians might be that it lends weight to calls for further training of clinicians. However,
where as in this case there is no valid predictive model in which the relative importance that
should attached by clinicians is known then the question becomes what might such training
be expected to deliver in terms of improving the predictive accuracy of the judgement
reached. Practitioners should be under no illusions regarding the irreducible uncertainties
involved in making short term predictions of suicide risk in in-patient settings no matter the
approach used (Simon, 2006). This does not mean that the present practice of routinely
incorporating consideration of such risk factors into the risk assessment process should be
abandoned. The significant limitations involved in predicting risk based only on such
information must however be acknowledged and greater efforts to incorporate a
phenomenological perspective on suicide risk assessment and management into practice
should be made.

Choosing a course of study and career in pharmacy—student attitudes and intentions across three years at a New Zealand School of Pharmacy

noreply@blogger.com (Landrogek) — Mon, 25 Feb 2008 18:24:00 +0000

Abstract
Factors influencing undergraduates’ selection of Pharmacy as a course of study, career, study and professional perspectives were evaluated by survey over the years 2004–2006 at Otago University, New Zealand. Altruistic intent emerged as a powerful motivator for choosing pharmacy and entrepreneurial career intentions were prominent. A sizeable though declining number
of students selected pharmacy secondarily to medicine or dentistry. Gender differences were found between intended areas of practice.

Introduction
Graduates from the National School of Pharmacy
(NSP) atOtago University represent just over half of all
Pharmacy graduates educated in New Zealand. In the
year 2006, these students constituted 45% of additions
to the practising register, with other significant
additions being from Auckland University (23%) and
UK/Ireland (21%; Pharmacy Council of New Zealand,
2005a). The motivations, career aspirations and
choices ofNSP studentswill therefore have a significant
influence on the future practice and culture of
Pharmacy both in New Zealand and on the work
overseas that many will pursue. Indirectly, selection
criteria used to admit students to the BPharm course
will also play a role in shaping the next generation of
pharmacists.
Choosing pharmacy as a course of study—demographics
and motivations
The choice by students of any undergraduate degree
involves many factors, including but not limited
to: socioeconomic variables, gender and ethnicity,
academic ability and academic self-concept, career
ambitions, personality, and prior educational attainment
(Van de Werfhorst, Sullivan, & Cheung, 2003;
Reay, Davies, David, & Ball, 2001; Pike, 2006; Porter
& Umbach, 2006; Abowitz, 2006). Recent studies in
the UK have indicated that there are increasing
numbers of women studying pharmacy, with almost
twice as many women as men qualifying as pharmacists
in 2005 (Hassell & Eden, 2006) leading to
pharmacy now being described as a “female-dominated”
profession (Hassell, 2003). The ethnic mix of
pharmacists in the UK is also becoming more diverse,
with around 25% of newly qualified pharmacists now
recorded as being “Asian British” (Hassell & Eden,
2006)—that is to say Indian, Pakistani or Bangladeshi—
compared with 4% of the population (Census,
1991/2001). Black British and Chinese ethnic groups
are also growing in representation (Hassell & Eden,
2006), though there is huge variability in the makeup
of course cohorts around the country (Willis,
Shann, & Hassell, 2006d).
Race or ethnicity has in a different way been shown
to be strongly associated with the pursuit of a
pharmacy degree and career. A US investigation into
whether individuals who had initially expressed an
interest in pharmacy subsequently pursued this field,
found that Hispanic or “other” ethnic group students
were 12 times more likely than White students to
continue with their plans to become pharmacists
(Cline, Mott, & Schommer, 1999). This study found
that those with higher grade point averages and career
commitments were also more likely to apply to study
pharmacy, suggesting that “despite pharmacy’s
uncertain future, it is still able to attract academically
qualified students” (P399). The role of ethnicity,
attitudinal traits and academic factors have been
found to interplay in other ways, for example with
family influence in choice of pharmacy as a career
reported to be particularly strong for non-White
students (Willis, Shann, & Hassell, 2006a).
The strongest motivating factor to study pharmacy
in the UK has recently been found to relate to its being
a science-based course, with other extrinsic and
intrinsic motivators also featuring—namely career
status and prospects, and a desire to help people and
to work with patients (Willis et al., 2006d). In
Australia, extrinsic factors relating to self-employment
and salary, and intrinsic factors relating to a liking for
science, interpersonal aspects and a desire to be socially
useful have all been found to influence students’ choice
of pharmacy as a degree (Roller, 2004). At the graduate
entry level, future employment prospects and a desire
to make a contribution to healthcare feature most
highly as factors influencing decision to study
pharmacy (Davey, Evans, & Stupans, 2006). Consistency
in motivations to study pharmacy across time and
cultures is indicated when it is considered that similar
findings relating to science, salaries and a “desire to
help humanity” were obtained in the US from the
1950s through to the 1970s (Cline et al., 1999; Pratt,
1956; Smith, Gibson, & Mikeal, 1974).
Around 75% of UK pharmacy students initially
chose pharmacy as their first course of study, with white
females most likely to take pharmacy as a first choice
(84%;Willis et al., 2006a). Ethnicity also emerged as a
factor in first degree selection, with almost four times as
many non-White students reporting pharmacy was not
their first choice of degree, compared with White
students. At the NSP, it is said to be “inevitable” that a
portion of undergraduates will not have opted first for
pharmacy, as the majority of students take a common
health sciences first year and subsequently compete for
entry to pharmacy, medicine, dentistry and physiotherapy
courses, for all of which they may apply at the end
of this year (Shaw, 2000).
Selection criteria
Admission to pharmacy at NSP is mostly based on
students obtaining a minimum of an average B grade
(70%) in the common health sciences first year.
A smaller number of students are admitted from
second or subsequent year of study, usually at Otago,
or as “competitive” graduates (of a New Zealand
university within the previous 3 years). An “alternative
applicant” category brings in a few others: those who
may have graduated from a New Zealand university
more than 3 years previously; those who have obtained
degrees, usually in medicine or pharmacy, from an
overseas university; and those who have worked as an
allied health professional (most often a pharmacy
technician or nurse) for 5 years or more. All such
applicants are required to have passed the subjects of
Otago’s common health sciences first year course (or
the equivalents) and to have demonstrated competence
in English. A certain degree of positive
discrimination exists in that students who are Maori
or Pacific Islanders may be brought into the BPharm
programme even if they achieve only an average of
65% or more during their pre-admission year(s). Only
about 1–2 students are admitted in this way each year,
however. Very few applicants for admission are
interviewed—only those applying as “alternative”
candidates and for whom English is not their first
language.
In the UK, A-level grades have been found to show
a small but significant correlation with grades at
pharmacy undergraduate level and thus it has been
argued that both teachers’ estimates of A-level
performance and actual A-level scores remain useful
in selection and forecasting (Foy & Waller, 1987).
A-level biology scores may perhaps be a stronger
predictor of performance in a pharmacy degree, and
English ability at entry level is also important as an
indicator of student success (Sharif, Gifford, Morris,
& Barber, 2003). Given that pharmacy undergraduates
must have the capacity to acquire diverse
scientific knowledge and skills, as well as developing
the knowledge and interpersonal skills of pharmaceutical
care, it is also reasonable to ask whether there
might be other selection criteria also applicable to
undergraduate admissions. With respect to the
contemporary focus of pharmacy practice as one
centred on patient care (Strand, Cipolle, Morley, &
Frakes, 2004), it has been suggested that formal
assessments of self-reported empathy be used in the
admissions processes of pharmacy schools. Similarly,
with reference to the scientific demands of the course,
that critical thinking skills and mathematical ability
should be taken into account, in addition to a range of
other non-academic and affective qualities (Duncan-
Hewitt, 1996).
The use of a variety of aptitude tests for pharmacy
admissions is now commonplace in the US (Chesnut &
Phillips, 2000), for example the Pharmacy College
Admission Test (PCAT; Duncan-Hewitt, 1996;
Chesnut & Phillips, 2000), which incorporates
measures of communication skills, reasoning ability
and chemistry- and biology-specific knowledge (American
Association of Colleges of Pharmacy, 2006).
Currently, no equivalent pharmacy admissions test
exists at the NSP; however, students pursuing entry
into medicine or dentistry from the common health
sciences first year are admitted in part according to
their performance on the UMAT (Undergraduate
Medicine and Health Sciences Admissions Test).
Given the potential relevance of various factors which
may be used in admissions, ranging from interpersonal
relations to problem-solving skills to ethical awareness
(Chesnut & Phillips, 2000), the novel step was taken
in this study to ask students themselves, what they
consider to be important and relevant selection
criteria for the pharmacy degree.
Career aspirations—professional intentions and influences
In the US, a study of eight Pharmacy Schools
indicated that the majority of students (71%) have
career aspirations that are strongly oriented towards
“direct patient care”, although concern is expressed
that this may be at odds with the realities of drug
distribution-based pharmacy likely to be encountered
in the professional workplace (Siracuse, Schondelmeyer,
Hadsall, & Schommer, 2004). This study also
found evidence that the more career-committed of
students will also be those aspiring to work in direct
patient care. Others have found that the “professional
subculture” of students entering pharmacy is comparable
to nursing and medical students as regards
their emphasis on patient care (Horsburgh, Perkins,
Coyle, & Degeling, 2006).
Pharmacy students in the UK apparently possess a
strong expectation that they will work very hard no
matter what pharmacy job they acquire—95% believe
this to be the case—and 80% state they are very
ambitious about their pharmacy career (Willis et al.,
2006a). Diverse factors have been shown to affect the
choice made by students about specific career paths,
including previous work experience, the influence of
sections of the undergraduate syllabus directed
towards pharmacy practice (Siverthorne, Price, Hanning,
Scanlan, & Cantrill, 2003) and practical matters
such as salary and work location, a desire for personal
fulfilment and to help patients (Carvajal & Hardigan,
1999; Carter & Segal, 1989).
As recently as 2000, concern has been expressed
that hospital pharmacy in the UK is said at the
undergraduate level to have an “image problem”,
being considered elitist, badly paid, dull and repetitive
(Hatfield, Marriott, & Harper, 2000). In contrast to
this (or perhaps evidence of a shift in attitude and
intention of students), more UK students stated that
they were at least “certain” that “in 10 years time”
they wanted a career in hospital pharmacy (60%)
compared to any other career option, although
significant interest was shown in community practice
(proprietor, 33%; employed by multiple, 51%),
working abroad (43%) and primary care (37%; Willis
et al., 2006a). Given that more than one option was
permitted in this survey, students do appear to be
hedging their bets to an extent, but these figures at
least suggest an open-mindedness about the practice
sites available to them.
Of those intending to work in the community sector
in the UK, strong entrepreneurial intentions are
evident, with 44% of male students and 28% of female
students saying they are certain they want to own a
pharmacy (Willis et al., 2006a) and pharmacy
ownership reported as the top ambition for students
(Wilson, Jesson, Langley, Hatfield, & Clarke, 2006).
The proportion of these individuals who will attain
their ambitions, given the decline of the independent
pharmacy in Britain, remains to be seen, however.
Consequences of the “feminisation” of pharmacy relate
to the likelihood of women working part time once in
their 30s, and gravitating towards temporary community
work (Hassell, 2003). It has been suggested also
that this feminising shift may at least correlate with
pharmacy itself becoming a more attractive career for
women than men (Gidman & Hassell, 2005).
Attitudes and career intentions in pharmacy have
not been as clearly elucidated in New Zealand.
However, given that currently 2100 (82%) of
pharmacists work in the community sector and 300
pharmacists (10%) in the hospital sector (Pharmacy
Council of New Zealand, 2005b) it could be valuable
to assess students’ perceptions of these and other
career paths.
Aims of this study
This study evaluated factors influencing students’
decisions to study pharmacy and to work as health
professionals, aswell as the characteristics they consider
important for selection to the course and for practising
pharmacy. Also investigated were pharmacy students’
career aspirations and intentions, and the relative
importance and attraction of various professional
activities and incentives. NSP students across three
separate cohorts and years were surveyed to examine
for commonalities and trends in these areas.
Method
This study, approved by the University of Otago
Human Ethics Committee, was developed in December/
January 2002/2003 following a series of interviews
and focus group discussions with current and recently
graduated students. It was piloted in 2003 by a
group of student researchers on that year’s second year
intake, following which a number of minor adjustments
were made to ensure consistency and ease of
analysis. The questionnaire has since then been
administered routinely to each incoming second year
class at the start of their first lecture, in the School of
Pharmacy. This first lecture which introduces students
to the School and pharmacy profession, is attended by
most students, all of whom have just been admitted
into the BPharm programme. The results presented in
this paper relate to the second year students of 2004–
2006.
The (anonymous) questionnaires were distributed
around the lecture theatre before the start of the lecture.
Students were then given 15 min to complete the
surveys and were asked to do so in silence, without
reference to their neighbours. At the end of the allotted
time, class representatives collected the completed
questionnaires and handed them to the academic staff
member present (who was not one of the researchers).
The questionnaire consisted of 24 separate questions,
many of which were subdivided into further
categories of choice. Most questions were multiplechoice,
requiring respondents to rate statements on a
Likert-type scale of 1–5, with 1 being not at all
important/ not at all interested through to 5 as most
important/ very interested. Other questions asked
students to rate order of importance of factors (e.g.
order of priority of factors influencing decision to
study pharmacy) or to make selections from alternatives
(e.g. ethnicity).
The following areas from the survey questionnaire
were analysed for the period 2004–2006:
1. Why do you want to work as a health professional?
(rating scale 1–5, 17 statements)
2. Which three of these factors (statements from
Question 1) were the most important in your
decision? (Please list in order of priority)
3. What, in your opinion, are the most important
attributes that the School of Pharmacy should
consider when selecting people for the Bachelor of
Pharmacy programme? (rating scale 1–5, 12
statements)
4. When you applied for admission to the Health
Sciences, was Pharmacy your first preference?
(yes/no) If not, please state which programmes
were preferred.
5. At this stage in your BPharm programme, do you
want to become a pharmacist? (yes/no)
6. Community pharmacists are involved in many of
the following activities in their day to day work.
Which activities are of most interest to you? (rating
scale 1–5, 11 statements)
7. What aspects of being a pharmacist are most
important to you? (rating scale 1–5, 14 statements)
8. During my working life, I would like . . . (tick as
many phrases as you feel apply [12 statements])
9. If you had to choose a pharmacy career path today, in
what field would it be? (Please tick one [6 options])
Further questions were also asked about gender,
age, ethnicity, language spoken and residency status.
Data were collated and analysed for all student
responses over the 3 years (n = 351) and separately for
each year to examine for trends. Participants’
responses between questions were not linked for the
2005 data, so analyses linking responses from different
questions are only presented for 2004 and 2006.
In addition to reporting descriptive statistics,
participants were forced to rank only three factors in
Question 2. Thus ranking data in Figure 1 represent
the mean number of times participants ranked a factor
as primary importance (3), secondary importance (2),
and tertiary importance (1). A score of 3 would
indicate all participants said a factor was the most
important; conversely a score of 0 indicates a factor
was not ranked in the top 3 by any participant.
Using the two smallest cohorts (2004 and 2006), it
was estimated using G*Power 3 that with 80%power, a
two-tailed pairwise comparison would be able to detect
an effect of d ¼ 0.38. By convention, values of 0.2 and
0.5 are considered to be small and medium respectively,
meaning that where differences were not found,
any real differences are likely to be close to small in size.
Results
A total of 351 students completed the survey (2004,
n ¼ 103; 2005 n ¼ 125; 2006, n ¼ 123) representing
98% of the total of three cohorts. All students in 2005
and 2006 completed the survey; 103 of 110 students
did so in 2004. There was a small level of nonresponse
on some questions, but this appears to be a
student accidentally omitting a question rather than
systematically not responding.
Motivations to study pharmacy
The left-hand panel of Figure 1 shows a strong degree of
consistency between years as to the primary ranked
motivations of students to work as a health professional
(Question 2). By far, the most highly ranked motivation
was a desire to work in a job where they “care for/
help people”, which was twice as highly ranked as
the next highest motivation, an “interest in human
biology”. A job involving interaction with people, a high
salary, a desire to work in the community, a desire to
own a business and a number of other aspects also
featured as important motivators. University publicity,
friends studying in the health sciences, family tradition
and “having high grades but not knowing what else to
do” were the least reported reasons for wanting to work
as a health professional.
The right-hand panel of Figure 1 presents mean
rating data for the same factors. Few trends across the
surveyed years were evident in students’ motivations to
work as a health professional, with the exception of a
desire for a “career in research”. Over the 3 years,
there was an approximately 15% increase in the
importance placed on this factor. It would seem
therefore that students coming into the pharmacy
course are increasingly explicitly considering a research
career at an early stage. It is also interesting to note the
difference in responses between the ranking and rating
data. For example, students were clearly interested in
learning new technology, but it was not a top priority.
Admissions criteria
Figure 2 shows that students rated being a good
communicator with good English (language skills) as
the top attributes that they considered the School
should considerwhen selecting people for the pharmacy
programme. Highmarks in health sciences first year and
in science at schoolwere also highly-rated, aswas having
an “orderly/controlled mind”. Those attributes considered
least important fromthe options presented were
a previous tertiary qualification, being an older student
and high marks in arts subjects at school.
Study and career commitment
A large, but slightly decreasing number of students
opted first for medicine or dentistry on application
from health sciences, with those opting for pharmacy
as their first choice ranging between 38 and 50%.
2006 was the first year of the three that more
students selected pharmacy as their first preference
than did not (50% (CI: 42–59) in 2006, vs. 38%
(CI: 30–47) in 2005 and 46% (CI: 36–56) in 2004).
One notable trend is the decreasing numbers of
students opting for medicine as their first preference,
from 38% (CI: 29–48) of applicants in 2004 to 33%
(CI: 25–41) in 2005 and 24% (17–32) in 2006.
There appeared to be an increasing conviction
among students that they wished to become “a
pharmacist”. In 2004, 82% (CI: 75–90) of students
stated they “want to become a pharmacist”, in 2005
this rose to 89% (CI: 84–95) and 2006 to 98% (CI:
95–100). Of the 3 students in 2006 who said they
did not, one stated they would prefer to go into
research.
Matters of interest and importance in a pharmacy career
There appeared to be a sharp division in interest in
aspects of the role of the community pharmacist,
between the “generic” work of selling products,
arranging staff duties and administration, and health
care-specificwork such as offering health promotionand
compounding drugs. Students rated the eight health
care-specific activities presented as being of similar
interest (each receiving an average rating of around 4 out
of 5) and the three generic items at around 3 out of 5
(Figure 3). Out of the eleven activities presented for
rating, students rated “listening to patients” and
“interviewing people” most highly, suggesting a
particular enthusiasm for the interpersonal aspects of
pharmacy work.
“Reliable employment” and “steady job” were the
highest-rated aspects of being a pharmacist followed
closely by “ability to travel” (Figure 4). A number of
other factors were also rated, including professional
status, a good salary and working in the health sciences
and in the community. The least-rated aspect is
“working in a retail shop”.
Looking at trends evident in Figure 4, there was a
slight decrease in importance placed on the “ability to
travel with my qualification” as an important aspect of
being a pharmacist over the years (though it is still
rated highly), a similar decline in the importance
placed on salary, and a corresponding increase shown
in the importance of “owning my own pharmacy”.
Career aspirations
Looking to the future, an overwhelming majority of
students (87% averaged over 2004–2006) stated that,
during their working life they would like to be able to
live and work outside New Zealand (Figure 5). There
is some evidence of this declining in later years. A high
proportion of students (62%) would like to find work
in New Zealand, however, and only 11% say they want
to move away from New Zealand permanently.
Over two-thirds of students, stated they would like
to own a business at some point during their working
life. Furthermore, when asked separately to indicate
what pharmacy career path they would choose “if they
had to today” the majority chose “owner, community
pharmacy (urban)”. This choice has remained
relatively constant over the years (Figure 6). There
has been a decline in the number of students stating
they would choose a career in hospital pharmacy. Only
small numbers of students each year (around 4%)
indicated they would choose a career as a lecturer or in
public administration.
Undergraduate demographics
New Zealanders of European descent made up the
largest proportion of students at NSP at 39% with
sizeable other groups being ethnic Chinese (19%),
Korean (9%), Taiwanese (7%), Malay (6%), (Fijian)
Indian (6%) and Middle-Eastern (5%), though it is
worth noting that there are 25 separate ethnic
groups/nationalities listed in responses.
The male to female ratio of students studying
pharmacy has been consistent since the mid 1970s, at
about two-thirds female to one-third male students
(64–36%). This contrasts with the university student
profile as a whole, which is 55% female and 45% male.
The majority of students beginning the course are 18
or 19 years old (around 80%), with around 15% aged
20–22, and less than 5% aged 23 or over.
Gender and ethnic differences
Gender differences were found to exist in the career
aspirations of students (Figure 7). Only 2004 and 2006
datawere able to be analysed for effects, and across both
years female students were more likely than males to
indicate that they would choose hospital pharmacy “if
you had to choose a pharmacy career path today”
(females 37% versus males 20%; p = 0.006). There
were no significant differences between male and female
students in their preferences for an urban pharmacy or
rural pharmacy career. However, male students were
twice as likely as female students to opt for research as a
career path (females 13% versus males 31%,
p , 0.001). When asked whether during their working
life students wanted to own a business, 89% of male
students indicated this as a careerambition,with 81%of
females saying they did, though this difference was not
significant.
Students’ ethnicity appeared to be one determinant
of whether they studied pharmacy as a first choice, with
New Zealand/European students far more likely to have
done so than students from other ethnic groups (63%
NZ European versus 37% all “others”; p , 0.001). It
was not possible to separate out different ethnicities in a
fully satisfactory manner because of issues with data
collection (changing census classifications) over the
years of study. Of those students who identified
themselves as “Chinese” (n = 38) or “other” Asian
(n = 42), however, less than half had selected
pharmacy as a first choice (n = 27) and one of the
eleven Taiwanese students (all of whom are Chinese by
ethnicity if not by politics) had done so. Differences by
ethnicity were found in terms of influences of parents.
None of the 2006 New Zealand European students
rated parental influence most highly in their decision to
become a health professional, indeed 70% gave it the
lowest possible rating. Parental influence on non-
European New Zealanders was more evenly spread
with 18% of students rating it as the most important
factor in their decision-making and only 33% rating it
as being least important.
Discussion
Motivations to study pharmacy
We have examined themotivation to study pharmacy in
a novel way, by asking students to rank which three
(of seventeen) factors had most influence upon their
choice, in addition to asking students to rate separately
the importance of the range of factors. This enables a
differentiation between factors that might appear at first
sight similarly salient (ratings), and those thatweremost
important in actually influencing a decision (factors
scored by rank). Using thismethod, themost important
motivation given by students in this study for choosing
pharmacyemerges as an intrinsic, altruisticone: that of a
desire to “care for/ help people”.
These findings are probably more pronounced than
those fromother research in this area but do correspond
with other studies of pharmacy students’ study choices.
These studies have consistently reported high prominence
of motivations to study broadly describable as
altruistic, such as “a desire to help humanity” (Pratt,
1956), aspiring to be “socially useful” (Ferguson,
Roller, & Wertheimer, 1986), a desire to make a
contribution to healthcare (Davey et al., 2006) and “a
desire to help people” (Willis et al., 2006a).
These and the current study’s results might seem to
imply that much of students’ motivation to study
pharmacy is in large part a deferred one, that is to say
directed towards their professional life after graduation;
however, other research has indicated that intrinsic
factors influencing the selection of a pharmacy degree
also relate to the course of study itself. Roller (1993)
found that the most important intrinsic or extrinsic
influences on Australian pharmacy students were that
the course was perceived to be “intellectually satisfying”;
however, students’ belief that pharmacy was
socially useful was also important. Willis et al. (2006d)
in the UK similarly identified the science-based nature
of pharmacy as the primary draw for students, but again
with the desire to help people also strong among
intrinsic factors. The current study did not ask directly
whether the course of study was inherently appealing,
although our finding that the second most important
reason why students selected the coursewas “an interest
in human biology” indirectly indicates this is likely to
have been relevant.
Extrinsic factors of most importance to students in
choosing to study pharmacy relate to a desire to earn a
high salary and to own their own business and, to a
lesser extent the status of the profession. Previous work
has also found that students are motivated to study
pharmacy for financial reward and the opportunity for
self-employment (Roller, 1993, 2004; Willis et al.,
2006d) with the most recent research in this area
claiming pharmacy ownership is the “top ambition for
students” (Wilson et al., 2006). Seston, Shann, Hassell
and Willis (2006) found that just under half of all UK
students report the prospect of ownership as having
some influence in their decision to study pharmacy,
with the effect particularly strong among male students
and ethnicminority students. Crucially, they also found
a strong link between the prospect of owning a
pharmacy as a reason for choosing pharmacy as a
degree, and career intentions after three years of study.
Career intentions and expected benefits
In the current study, there appeared to be an early
explicit intention expressed by students to pursue
a career in pharmacy: 121 of 123 respondents in
2006, stated that they want to become a pharmacist,
a proportion that has increased over the three
surveyed years. This result is striking for its being
obtained at a very early stage in students’ course of
study, where one might reasonably expect some
ambivalence towards the degree (though it should be
noted that students were not given the option of
expressing uncertainty). These high rates of commitment
to a career as a pharmacist may relate to other
findings which indicate pharmacy students are careercommitted
(Willis et al., 2006a) and the finding in this
study, that in 2006 for the first time more students
selected pharmacy than any other health profession as
their first choice of study. In 2004 and 2005, as many
of those surveyed had wished to study medicine as
pharmacy, whereas in 2006 over twice as many
students opted for pharmacy as medicine. Despite
this, large numbers (almost half) of NSP students
would have preferred to follow another profession,
usually dentistry or medicine, as has been noted
previously (Shaw, 2000). The tendency for European
New Zealand students to be more likely than ethnic
minority students to have chosen pharmacy as a first
choice is in keeping with other studies which have
found similar ethnic differences in application
priority. This result is curious though for its being
apparently robust across courses, countries and
cohorts (Ferguson et al., 1986; Willis et al., 2006a),
despite the very different actual mix of ethnicities
studying pharmacy between New Zealand, Australia,
Canada, the US and the UK. It may be of concern to
educators that ethnic minority, foreign-born or
overseas students appear to be those most likely to
be studying pharmacy as a second (or lower) choice,
particularly considering the high, and in many
instances increasing, proportion of these students on
pharmacy courses.
Since over two-thirds of students indicated that they
would like at some point in their working life to own
their own pharmacy, New Zealand students’ entrepreneurial
intentions seem as strong as their UK
counterparts (Seston et al., 2006). Interestingly, there
was a decline in the proportions selecting hospital
pharmacy as a desired career path over the years
surveyed.
With so many students wanting to own their own
pharmacy, the question should be asked to what extent
these ambitions are realisable. In theUK, they may well
not come to fruition “given the steady decline of
independent pharmacies through competition from
multiples over recent years and an economic climate
that is not favourable to small pharmacy business”
(Seston et al., 2006). The potential for proprietorship is
higher in New Zealand, which has a long tradition of
individual ownership. Recent changes in legislation,
however, have enabled pharmacists to have a share in
up to five pharmacies, with the consequence that
groups of pharmacists have banded together to form
some small chains of pharmacies, run by manager
pharmacists rather than owners. It will therefore be
important for educators in New Zealand and elsewhere
to be aware that students’ ambitions for individual
ownership may not remain viable.
That hospital pharmacy sector suffers an “image
problem” (Hatfield et al., 2000) is also not so much an
issue in New Zealand, where anecdotal evidence
suggests that pre-registration hospital placements are
more sought after than community internships. The
tendency for females to be significantly more interested
in hospital work than males found in this current
study is in keeping with UK findings (Willis et al.,
2006b) and findings spanning the US, Canada and
Australia (Ferguson et al., 1986). These findings seem
likely to be borne out by students’ career trajectories in
the UK, where three times as many women as men
work in hospitals (Hassell, 2003).
This well-documented gender difference may relate
to hospital pharmacy offering more flexible hours and
institutional benefits (Cockerill & Tanner, 2001), and
also be related to gender differences in entrepreneurial
ambitions, given the generally lower salaries pertaining
in the sector. Other research looking at UK
pharmacy students’ perceptions of hospital pharmacy
suggests that it is perceived by students to offer poor
salaries but more opportunities to interact with
patients and better career progression (Silverthorne
et al., 2003). However, Hassell (2003) identified
concerns among some UK pharmacists that a “glass
ceiling” exists for female hospital pharmacists,
resulting in them being under-represented in senior
positions in this field. This is not the situation in New
Zealand; however, where, in 2006, almost 70% of the
chief pharmacists working in the country’s main
hospitals were female.
As for student aspirations to pursue a career in
research, New Zealand differs from Europe or the US
in that it has only a small pharmaceutical research
industry and only two Schools of Pharmacy, which
may explain the relatively low numbers of NSP
students interested in this career pathway. Interest in a
research career, though still quite limited, is growing
and may increasingly be considered by students to be a
viable career option.
In the current study, students perceived from an
early stage the associated benefits of a pharmacy
career, foremost among these being reliable employment
and the ability to travel with their qualification.
Aspects such as being a professional, working in the
community and earning a good salary also feature as
important facets of being a pharmacist. These and
other factors—such as undergraduate practice and
work experiences (Silverthorne et al., 2003)—are
likely to play a part in influencing the particular career
trajectories of students. Perhaps contrary to expectations,
Carvajal and Hardigan (1999) have also
suggested that females are more likely than males to
experience job satisfaction from high salary and retail
work. This finding did not emerge in the current study
but would be worthy of future attention.
The diminishing importance given by students to an
ability to travel as pharmacists from 2004 to 2006 may
be a consequence of the recent ending of direct
reciprocal employment agreements between the UK
and New Zealand, which has traditionally been a
popular route for New Zealand pharmacists to engage
in their “overseas experience”. Despite this decline, it
should be noted that almost 90% of students still say
they would like to be able to live and work outside
New Zealand at some point in their lives. This finding
may be particular to New Zealand where it is
especially common for university graduates to travel
and live abroad for a few years, usually within the first
10 years post-registration.
Admissions criteria
When asked to consider what might constitute
appropriate admissions criteria for the BPharm
programme, students report that “being a good
communicator” was more important as a selection
criterion than any other of the hypothetical admissions
criteria presented to them, more so even than high
marks in the health sciences common first year
or school science subjects. Speaking English well was
rated highly, and this aligns with research that has
found English skills to correlate highly with final
pharmacy exam marks for non-native English speakers
(Sharif et al., 2003). Science marks and the critical
thinking/scientific capacity indicator “having an
orderly and controlled mind” also featured highly in
students’ opinion of appropriate admissions criteria.
These results regarding student appraisal of what
might be important admissions criteria taken together
are an interesting indicator of students’ own perceptions
about what constitutes a good pharmacist and a
capacity to do well in the degree course: a combination
of good communication skills and cognitive ability. It
has been argued in the pharmacy education literature
that empathic and other non-traditional measures
should be used in student selection (Duncan-Hewitt,
1996; Wright & Miederhoff, 1999). At the university
where this study was conducted such measures are not
currently used in student selection for pharmacy,
though they are in medicine and dentistry. Whether to
use such measures in pharmacy admissions is likely to
arouse continuing controversy, not least because it is
now possible for students to be coached in how to
perform well in these tests in such a way that may be
construed as “faking” their true attitudes.
Aspects of interest in pharmacy practice
Interpersonal/empathic aspects again emerged as
aspects of being a pharmacist of most interest to
students, with “listening to patients” and “interviewing
people” receiving the highest ratings. There appears
overall to be a pronounced division in opinions of the
two facets of professional pharmacy practice: students
perceive non-patient-centred aspects of work, such as
administration and selling products, to be less attractive
than the range of patient-centred work. This may be a
sign that students are already conceptualising pharmacy
work as comprising two different types of
activity—indirect and direct patient care—and that
they are inherently more interested in the latter. This
result is perhaps not surprising, and matches other
research indicating students aspire more to involvement
in direct patient care than indirect patient care, with the
latter described as being “product-focused” or involved
with “drug distribution” (Siracuse et al., 2004). Such
attitudes on the part of students would seem to be in
keeping with the altruistic, patient-centred motivations
expressed for studying pharmacy in the first place.
The current study’s results may in a positive way be
placed in the context of Davey et al.’s (2006) remark
that “as pharmacy practice continues to emphasise
patient interface it is encouraging to see that a
contribution to health care is of more significance (to
students) than the status of the degree”. A cautionary
note may also be added though, that in light of these
findings it will be important to consider in future
research the extent to which students’ expectations and
aspirations are matched by the realities of the workplace,
where “for many pharmacists, there is a clear
disconnect between what pharmacy leadership says
pharmacists should be doing and the reality faced by
practising pharmacists on a daily basis” (Siracuse et al.,
2004) especially in terms of the administrative and
bureaucratic demands of small business management.
Undergraduate demographics
The approximate 2:1 ratio of female:male students at
the NSP corresponds with what seems now almost to
be becoming an education standard for this increasingly
female-dominated profession (Hassell, 2003).
Whilst registers of practising pharmacists consist at
present of 53% females in the UK and New Zealand
(Hassell, 2003; Pharmacy Council of New Zealand,
2005b) this seems destined to change. There are
implications for workforce supply, as the current UK
register shows a far greater degree of part-time hours
worked by women in their 30s and 40s thanmen of the
same age group, which in part is due to family building
(Willis et al., 2006c). A similar trend towards
feminisation has been observed in other health
professions, including medicine and dentistry, in the
US, the UK and Australasia, where similar consequences
have been predicted as a result.
The student body at the NSP is noteworthy in that it
is very diverse and unique to this pharmacy school.
Whereas, well-represented ethnic minorities in pharmacy
in the UK are “Asian British”, that is to say
British students of Indian, Pakistani and Bangladeshi
origin, in New Zealand the ethnic origin of (mostly
New Zealand-resident) minority students are mostly
represented by Chinese, Taiwanese, Koreans and
Malaysians, with those from Arabic and other backgrounds
also rising in numbers. Given the high
diversity, there is likely to be consequent variability in
the learning behaviours of students that educators
may increasingly need to take into account (Miranda,
Bates, & Duggan, 2002).
Limitations and suggestions for future research
A social desirability effect on the self-report measures
in this study may be pronounced because the survey
asked about explicitly socially desirable factors such as
“desire to care for/help people”. A strength of this
study is the very high response rate (98%) obtained,
largely through our distribution of the survey during
compulsory course elements. Although the questionnaire
used in this study was based in part on surveys
used in previous research into pharmacy student
choices, its reliability and validity were not separately
tested. Indicators of reliability and validity however
include the emergence of dual factors from questions
pertaining to direct and indirect patient care and the
congruence of certain career- and study-related
motivators emerging in separate areas of the survey,
for example in the intention and aspiration to own a
business. It is the authors’ intention to use a followup
questionnaire in longitudinal research with the
cohort surveyed in 2004–2006, which may give
further indications of its validity and reliability.
A particular point for concern for this and similar
studies is the apparently limited extent to which
physicians have accurate retrospective recall of the
causes of their own behaviour in relation to career
choice (Pathman & Agnew, 1993).
Future work might focus on extending knowledge of
intrinsic and extrinsic factors in choice of profession by
placing the choice of pharmacy as a degree and career
against a wider social context. The extent to which
socioeconomic factors and family background influence
students’ decisions might be further considered, for
example. Large-scale work has indicated that “professional”
class background can have a particular
positive effect upon the choice of prestigious degrees
such as medicine and law (Van de Werfhorst et al.,
2003). These authors also presented evidence that
educational systems are institutionally biased towards
students who possess “cultural capital”, which makes it
difficult for working-class students to succeed in the
education system. Furthermore, because of differential
costs and benefits between class backgrounds, professional
career trajectories are less easily attainable for
working-class students. In the health sciences, differences
in career choice have been found between lowand
high income family backgrounds of medical students
(Cooter et al., 2004). It is not known whether such
influences are as important in New Zealand, where
social systems are perhapsmore fluid. Neither has there
been any examination of whether the cost of study—
which ranged in 2006 from US$3300 per annum for
physiotherapy toUS$3850 for pharmacy andUS$7400
for medicine/ dentistry—influences students’ choice of
career. Nevertheless, it is a matter for concern that the
proportion of BPharmstudents who identify asMaori is
well below the proportion of Maori in the general
population (1–2% compared with 12%).
A further limitation of this study is that it was
focussed to a large extent on students’ intentions,
which may vary over their course of study and may
also not manifest in reality. Edwards, Lambert,
Goldacre, & Parkhouse, (1997), for example, reported
that ten years after graduating only two-thirds of
medical students end up working in the field they
intended to during study. It will be of value in future
research therefore to ascertain the extent to which
students follow through with their intentions, which
will better inform the reliability and validity of this and
similar survey tools and, more importantly, to what
extent expectations and aspirations of pharmacy
students are realised in the workplace. This would
have significance for those promoting pharmacy
degrees and admitting students to their courses, as
to what character of advice is most appropriate and
honest to offer to these aspiring professionals.
Summary and conclusions
This study, as well as previous research across a range
of cohorts, courses and countries, offers a generally
consistent view of the motivations of students to study
pharmacy and work as a health professional. Whereas
other research has suggested that altruistic intent may
be similar in importance to other factors, this study’s
results point to a clear prominence for this particular
factor.
Scientific aspects inherent to pharmacy as a course
of study also act as attractors to the subject area and
pharmacy is perceived in favourable terms as offering
good employment prospects with considerable entrepreneurial
potential. A tendency still exists among
many first year pharmacy students to have selected
medicine or dentistry as a first choice, particularly
among ethnic minority students, a tendency which
may be declining but is likely to be to an extent
inevitable, particularly with a system in which all
students take the same first year curriculum. The
picture among the undergraduate cohort, nevertheless,
is of committed individuals who intend to
pursue a pharmacy career. Gender differences
were shown to emerge between aspirations to work
in the different sectors, and in pharmacy
ownership intentions. The perceived value of a
pharmacy “passport”, and intention to travel with it
is very high among NSP students and will see many
working overseas. Students perceived that good
communication and English skills are of greatest
importance when considering potential entrants to the
course, a belief borne out by the literature. Yet the
Pharmacy School’s admissions process does not place
a greater emphasis on this requirement (which is
currently assessed by means of a paper on Effective
Communication, provided by the University’s English
Department) than any of the other papers of the
compulsory health sciences first year course, despite
the fact that many of its students have English as a
second language.
There is some concern about the extent to which
students’ desire and intentions to own a pharmacy
will be realisable in the future and also the extent to
which students’ experience in community pharmacy
after registration will match their expectations and
preferences.
Future focus for research that elucidates the wider
range of factors likely to influence students’ pursuance
of pharmacy, such as that which relates to family, class
or cultural background is suggested. Also of importance
will be work that better investigates the link
between students’ education and ambitions and the
realities of their professional life.

Additional Antihypertensive Effect of Drugs in Hypertensive Subjects Uncontrolled on Diltiazem Monotherapy: A Randomized Controlled Trial

noreply@blogger.com (Landrogek) — Mon, 25 Feb 2008 18:21:00 +0000

The purpose of this study was to compare several diltiazem-based antihypertensive drug
combinations and assess the usefulness of home blood pressure monitoring in the evaluation
of the efficacy of combination pharmacotherapy. Sixteen general practitioners
recruited hypertensive subjects uncontrolled on diltiazem monotherapy, who were randomized
to receive eight weeks of add-on therapy with a diuretic (chlorthalidone), a
dihydropyridine calcium antagonist (felodipine), an ACE inhibitor (lisinopril), or an
angiotensin blocker (valsartan). Sitting office and home blood pressure was measured
using electronic devices A&D 767. A total of 211 patients were randomized, and 185
completed the study. Of 52 subjects randomized to felodipine, 15 were withdrawn due to
ankle edema. The additional antihypertensive effect of the second drug was smaller in
18 subjects with a white coat effect (p < 0.01). All combinations produced a significant
decline in office (21.2 ± 14.8 / 7.7 ± 9.7 mmHg) and home (17.1 ± 11.9 / 6.0 ± 7.0) blood
pressure (systolic / diastolic, p < 0.001). There were no differences in the efficacy of the
four combinations assessed using office or home blood pressure monitoring. These data
suggest that diuretics, dihydropyridines, ACE inhibitors, and angiotensin receptor
blockers provide significant additional antihypertensive effects in hypertensive patients
uncontrolled on diltiazem monotherapy. The diltiazem-dihydropyridine combination is
often intolerable because of ankle edema. Home blood pressure monitoring is useful in
the assessment of the efficacy of combination pharmacotherapy and also allows for the
detection of subjects who do not require treatment intensification.

Introduction
There is agreement among hypertension guidelines that diuretics, b-blockers, calcium
antagonists, ACE inhibitors, and angiotensin receptor antagonists are appropriate to be
used as first line treatment in hypertension (1–3). Moreover, it is recognized that in order
to achieve the recommended blood pressure (BP) goals, combination pharmacotherapy is
required in the majority of hypertensive patients (1,2). It is clear, however, that more clinical
research from randomized comparative trials on the efficacy and tolerability of antihypertensive
drug combinations is needed (1).
Non-dihydropyridine calcium antagonists are effective antihypertensive drugs and are
being widely used in clinical practice (4). Outcome trials have shown that these drugs
improve cardiovascular prognosis in hypertensive patients with or without coronary heart
disease (5,6). Some short-term studies have assessed the antihypertensive effects of
combined treatment of non-dihydropyridine calcium antagonists with thiazide diuretics
(7–9) or angiotensin-converting enzyme (ACE) inhibitors (10,11). However, the evidence
on the combination of these drugs with dihydropyridines or angiotensin blockers is very
limited (12,13). In addition, no direct comparison of these combinations in regard to their
antihypertensive efficacy has been reported.
Self-blood pressure monitoring at home is regarded as an important adjunct to office
measurements in hypertensive patients and is being increasingly used in clinical practice
(1,2,14,15). Accumulating evidence suggests that home BP is devoid of the white coat (16)
and the placebo effect (14) and provides highly reproducible BP values (17). Therefore,
home BP has been recently used in several trials to assess the efficacy of antihypertensive
drugs, and it has been suggested that the use of this method instead of the conventional
office measurements can improve the accuracy of antihypertensive drug trials (14,17).
The objectives of this study are to (1) assess the additional antihypertensive effect of a
thiazide diuretic versus a dihydropyridine calcium antagonist, an ACE inhibitor, and an
angiotensin receptor blocker in hypertensive patients uncontrolled on diltiazem monotherapy,
and (2) compare self-home BP measurements with office BP measurements in the
assessment of the antihypertensive effect of combination pharmacotherapy.
Subjects and Methods
Physicians and Patients
Trained general practitioners employed in primary care recruited subjects aged 25–79
years with uncontrolled hypertension after at least four weeks of open monotherapy with
diltiazem at 240 mg o.d. Uncontrolled hypertension was defined as average office BP
greater than 140/90 mmHg for all or 135/85 mmHg for diabetics or subjects under the age
of 65, confirmed on two office visits at least one week apart (3).
Design
Participants were randomized to receive one of the following open add-on therapies for
eight weeks:
1. thiazide diuretic chlorthalidone 12.5 mg o.d.,
2. dihydropyridine calcium antagonist felodipine 5 mg o.d.,
3. ACE inhibitor lisinopril 10 mg o.d., or
4. angiotensin receptor blocker valsartan 80 mg o.d.
Add-on treatment was doubled if office BP remained uncontrolled after four weeks of randomized
combination pharmacotherapy. All antihypertensive drugs were taken in the
morning just after rising from bed. The study protocol was approved by the Quality Assurance
Committee of the Greek Association of General Practitioners. Participants gave
informed consent for study participation.
Exclusion criteria included the following:
• contraindication or known intolerance of diuretics, calcium antagonists, ACE inhibitors,
or angiotensin blockers;
• compelling indication for treatment with a specific antihypertensive drug class;
• nephropathy, coronary heart disease, congestive heart failure, major cardiac, hematological,
or hepatic or pulmonary disease;
• cerebrovascular event in the three months prior to study entry;
• any other clinically significant illness based upon recent medical history, with the
exception of stable diabetes type-2 on diet alone and/or by oral hypoglycemic agents;
• evidence of secondary hypertension;
• systolic BP >200 mmHg and/or diastolic >110 mmHg at any time during the study;
• therapy with any drug likely to influence BP, including diuretics and NSAIDs
(excluding aspirin up to 300 mg per day); and
• clinically important abnormalities of baseline laboratory data.
Measurements
Office BP was measured by general practitioners at trough before randomization and after
four and eight weeks using validated electronic devices A&D 767 (18) (bladder size 12 × 23
cm or 14 × 2 8 cm, where appropriate). Triplicate measurements were taken at each visit
after 5 min sitting rest and 1 min between readings, and the average was used for decision
making (randomization and titration). Home BP was monitored by the patients themselves
on three routine workdays in the week before randomization and after four and eight weeks.
Self-measurements were taken by the patients at home using the same device and cuff as
office measurements (A&D 767). Participants were trained in the conditions of home BP
measurement and the use of the devices and were instructed to perform duplicate morning
(0600–1000 h, before morning drug intake) and evening (1800–2100 h) measurements after
5 min sitting rest and 1 min between recordings. A form was supplied to the patients to
report self-home BP values. The average of all home measurements was used in the analysis.
Physical examination, body weight measurement, and 12-lead ECG were performed
before randomization and after four and eight weeks. Routine hematology and biochemistry
and urine dipstick and microscopy were performed within four weeks prior to study
entry. Depending on the randomized regimen, selected tests were repeated after four and
eight weeks according to current hypertension recommendations (1–3). An assessment of
adverse reactions was performed at each office visit.
Analysis
Taking into account that home BP was used in a four-group parallel design, in order to
have a probability greater than 0.9 (study power) to detect between treatment groups differences
of 10/5 mmHg in systolic/diastolic home BP at p < 0.05, a total of at least 180
subjects with complete data should be studied (estimated standard deviation of differences
for home systolic/diastolic BP = 7/5 mmHg (17); clinically important between periods
difference ≥ 10/5 mmHg in home systolic/diastolic BP; corrected for multiple comparisons).
Paired t-tests were used to assess treatment-induced changes in clinic and home BP
and unpaired t-tests for between-groups comparisons of antihypertensive drug effects. A
Bonferroni’s correction for multiple comparisons was applied where appropriate.
Results
A total of 211 subjects were recruited by 16 general practitioners and randomized. Fifty-four
subjects were randomized to receive add-on chlorthalidone; 52, felodipine; 54, lisinopril; and
51, valsartan. Twenty-six subjects were withdrawn after randomization, of whom 22 (10.4%)
due to adverse drug effects (17 due to ankle edema) and 4 (1.8%) due to missing follow-up
data. Ankle edema was observed in 15 subjects on felodipine (29%), 1 on valsartan (0.5%), 1
on chlorthalidone (0.5%), and none on lisinopril (p < 0.001). Data from the remaining 185 subjects
with complete follow-up were included in the final analysis, of whom 51 (27.6%) were on
chlorthalidone, 36 (19.5%) on felodipine, 50 (27.03%) on lisinopril, and 48 (25.9%) on valsartan.
The mean age of the 185 subjects was 63.9 ± 10.6 years, 80 (43%) were men, the mean
body mass index (BMI) was 28.7 ± 4.6 kg/m2, and 41 (22%) had type-2 diabetes.
Average office BP at randomization was 158.6 ± 13.1 / 86.1 ± 9.4 mmHg (mean ±
SD, systolic / diastolic), whereas average home BP was significantly lower (150.3 ± 13.3 /
83.0 ± 8.6 mmHg; p < 0.001). There was no significant difference among randomized
groups in regard to patients' age, sex, BMI, proportion of diabetics, and baseline office or
home BP (see Table 1). Eighteen subjects (10%) had average home BP <135/85 mmHg at
randomization and where classified as having a white coat effect. After four weeks of
combination pharmacotherapy, the dose of the second drug was doubled in 113 subjects
(61%) because of an uncontrolled office BP. There was no difference among randomized
groups in the proportion of subjects in whom randomized treatment was doubled.
Table 1
Baseline characteristics of participants in the four randomized treatment
groups (mean ± SD)
Thiazide
diuretic
Dihydropyridine
ACE
inhibitor
Angiotensin
blocker All drugs
Subjects 51 36 50 48 181
Age (years) 63.5 ± 9.9 64.7 ± 9.8 62.6 ± 12.9 65.2 ± 8.6 63.9 ± 10.5
BMI (kg/m2) 28.7 ± 4.2 28.2 ± 4.7 28.1 ± 4.7 29.3 ± 4.3 28.6 ± 4.6
Men (%) 24 (47) 15 (42) 20 (40) 21 (44) 80 (44)
Diabetes (%) 16 (31) 5 (15) 8 (49) 12 (47) 41 (22)
Office BP (mmHg)
Systolic 159.6 ± 13.6 160.2 ± 16.0 157.7 ± 11.4 157.7 ± 12.2 158.6 ± 13.1
Diastolic 86.5 ± 9.3 87.1 ± 8.1 86.1 ± 10.5 85.0 ± 9.7 86.1 ± 9.4
Pulse rate 75.2 ± 8.3 77.8 ± 7.9 77.1 ± 10.7 73.2 ± 9.5 75.7 ± 9.4
Home BP (mmHg)
Systolic 148.6 ± 14.1 152.4 ± 14.0 151.2 ± 14.2 149.7 ± 10.9 150.3 ± 13.3
Diastolic 82.7 ± 8.5 83.6 ± 8.6 83.5 ± 8.8 82.0 ± 8.3 83.0 ± 8.6
Pulse rate 72.1 ± 8.1 74.2 ± 7.5 72.4 ± 6.9 70.5 ± 8.9 2.2 ± 7.9
BMI: body mass index; BP: blood pressure.
Significant decline in both office and home BP was achieved during the study (see
Table 2). The additional antihypertensive effect obtained by the second drug was significantly
greater in subjects without compared to those with a white coat effect (Table 2).
This difference in the antihypertensive effect was more pronounced and reached statistical
significance when home BP monitoring was used (average home BP decline 8.0 / 2.8
mmHg systolic / diastolic in subjects with a white coat effect versus 17.1 / 6.0 mmHg in
the others; see Table 2). All drug combinations induced a significant decline (p < 0.001) in
both office and home BP during the study (see Table 3). There were no significant differences
in the additional antihypertensive effects of the four drugs assessed using either
office or home BP monitoring.
Discussion
This study compared the efficacy of four diltiazem-based antihypertensive drug combinations
using office and home BP monitoring. The study showed that a thiazide diuretic, a
dihydropyridine calcium antagonist, an ACE inhibitor, and an angiotensin receptor
blocker provide significant additional antihypertensive effects in hypertensive patients
uncontrolled on diltiazem monotherapy. However, the diltiazem-dihydropyridine combination
was often intolerable because of significant ankle edema. In addition, the study
showed that home BP monitoring is at least as effective as the conventional office measurements
in the assessment of the efficacy of antihypertensive drug combinations and
also allows for the detection of subjects who do not benefit from treatment intensification.
Studies have shown additional antihypertensive effects of diltiazem combined
with hydrochlorthiazide (7–9). Furthermore, several hypertension trials have investigated
the efficacy of combining non-dihydropyridine calcium antagonists with ACE
inhibitors, and fixed dose combinations of these drug classes have been developed
(10,11). However, in regard to the angiotensin blockers, there are no published studies
of the antihypertensive efficacy of these drugs in combination with non-dihydropyridine
calcium antagonists.
The combination of non-dihydropyridine calcium antagonists with dihydropyridines
remains controversial. Receptor binding studies have suggested that this combination
might result in either enhanced or diminished pharmacological effects (12). However, the
evidence from clinical trials on the antihypertensive efficacy and the tolerability of this
combination is very limited (12,13). A small randomized study in hypertensive patients
uncontrolled on nifedipine monotherapy showed significant additional antihypertensive
effects with either diltiazem or verapamil (12). That study provided evidence that the additional
antihypertensive effect is due to a pharmacokinetic interaction between diltiazem
and nifedipine (12). In another randomized comparative study of diltiazem versus nitrendipine
in patients with hypertension and stable angina, an additional antihypertensive
effect without additional side effects was observed in a subgroup of 16 subjects who
received both drugs because of uncontrolled BP on monotherapies (13). In contrast, the
present study showed that the diltiazem-felodipine combination is associated with intolerable
ankle edema in 30% of subjects. This adverse effect might be attributed to the high
dose of calcium antagonist rather than to a drug interaction, given that the incidence of the
calcium antagonist-induced vasodilatory ankle edema is the most common side adverse
effect of these drugs that leads to withdrawal and is clearly dose-dependent (19). It should
be noted that the abovementioned studies that assessed the efficacy of the combination of
non-dihydropyridine calcium antagonists with other antihypertensive drugs have compared
combination therapy with monotherapies, whereas the present study provided a
direct head-to-head comparison of the antihypertensive effect of four non-dihydropyridine
calcium antagonist-based combinations.
In this study, both office and home BP measurements were taken using validated
automated devices. This approach increases the reliability of measurements by preventing
observer bias and the terminal digit preference, which are known to be present using conventional
auscultatory BP measurements (14). Significant additional antihypertensive
effects were detected in this study using either office or home BP measurements (Table 3).
However, the use of home BP monitoring allowed for the detection of a significant white
coat effect in 10% of study participants (16). Recent recommendations suggest that subjects
with the white coat phenomenon do not benefit from treatment intensification
(1,2,14). In line with these recommendations, this study showed that in subjects with a
white coat effect, the magnitude of the decline in home BP was less than half of that
achieved in the rest of study participants (Table 2). It is clear that the implementation of
home BP monitoring in clinical trials aiming to assess the efficacy of antihypertensive
drugs allows for the exclusion of subjects with the white coat effect, thereby increasing the
study power or reducing the number of subjects required (16,17). On the other hand, the
use of home BP in clinical practice is essential for the detection of treated hypertensives
with a white coat effect in order to prevent unnecessary, costly, and potentially harmful
additional pharmacotherapy. These benefits of home BP monitoring are attributed to the
facts that measurements are taken away from the office setting and to the larger number of
readings obtained (14–16).

Illicit drug use and dependence in a New Zealand birth cohort

noreply@blogger.com (Landrogek) — Mon, 25 Feb 2008 18:17:00 +0000

Objective: To describe the patterns of illicit drug use in a birth cohort studied to the age
of 25 years.
Method: The data were gathered during the Christchurch Health and Development Study.
In this study a cohort of 1265 children born in the Christchurch, New Zealand urban region
in mid-1977 have been studied to the age of 25 years. Information was gathered on
patterns of illicit drug use and dependence during the period 15–25 years.
Results: By age 25 years, 76.7% of the cohort had used cannabis, while 43.5% had used
other illicit drugs on at least one occasion. In addition, 12.5% of the cohort met DSM-IV
criteria for dependence on cannabis, and 3.6% of the cohortmet criteria for dependence on
other illicit drugs at some time by age 25. There was also evidence of substantial poly-drug
use among the cohort, with hallucinogens and amphetamines being the most commonly
used illicit drugs (excluding cannabis). Illicit drug use and dependence was higher in
males, in M¯aori, and in those leaving school without qualifications. Key risk factors for illicit
drug use and dependence included adolescent risk-taking behaviours including cigarette
smoking and alcohol consumption, affiliation with substance-using peers, novelty-seeking,
and conduct problems in adolescence. Other key risk factors included parental history of
illicit drug use and childhood sexual abuse.
Conclusions: Levels of cumulative illicit drug use in this cohort were relatively high, with
the majority of respondents having tried illicit drugs by age 25. For the majority of illicit
drug users, drug use did not lead to problems of dependence. Nonetheless, nearly 15%
of the cohort showed symptoms of illicit drug dependence by the age of 25 years, with
cannabis dependence accounting for the majority of illicit drug dependence.

In recent years there has been growing concern about
the use of illicit drugs in young New Zealanders. This
concern has been reflected in a number of government
and local initiatives aimed at reducing the use of illicit
drugs and minimizing the harm caused by illicit drug use
[1,2]. These plans acknowledge the extent to which the
use and misuse of illicit drugs represents a critical social
issue with implications for the health and safety of a large
number of New Zealanders.
The importance of the issue of illicit drug use is illustrated
by periodic cross-sectional surveys of illicit drug
use in New Zealand. These surveys have provided evidence
that illicit drug use is common among New Zealanders,
is particularly common in young people, and may
be increasing. For example, Wilkins et al. [3] reported
that approximately 52% of respondents aged 15–45 had
reported using cannabis on at least one occasion in their
lives. For illicit drugs other than cannabis, 4% of respondents
reported having used opiates, 15% reported
using hallucinogens and 11.9% reported using stimulants
(including cocaine, amphetamine/methamphetamine and
derivatives of these) at least once in their lives [3]. Furthermore,
Wilkins et al. [3] reported that patterns of
use appeared to be age dependent with the highest incidence
of use in the previous year being reported by
those in the 18–24 years age range. In this group, approximately
35% of the sample had reported using cannabis
on at least one occasion in the previous year, and 21%
reported having used other illicit drugs on at least one
occasion in the previous year [3]. Comparisons between
1998 and 2001 surveys suggested that there was an increase
in the rates of other illicit drug use, particularly
for hallucinogens and stimulants [3]. The percentage of
the sample reporting having used hallucinogens on at
least one occasion increased from 12.8% to 15%, while
the percentage of those reporting having used stimulants
increased from 9% to 11.9% [3].
It should also be noted that a number of studies examining
the prevalence and incidence of illicit drug use
in New Zealand and overseas have been cross-sectional
studies. Although these have provided valuable data on
illicit drug use, it would be of particular importance to
examine prospective, longitudinal data on illicit drug use.
Longitudinal data provide more accurate estimates of cumulative
use over the life span than retrospective reports
of past use [4], as well as more accurate estimates of such
factors as age of onset and the timings of the occurrence
of other risk factors [5].
In light of these concerns and methodological issues,
there is a need for further detailed information on patterns
of illicit drug use among adolescents and young adults.
To address this, the present paper reports on the results
of analyses of cumulative measures of illicit drug use
and dependence in a birth cohort of young New Zealanders
studied to the age of 25. The specific aims of this
investigation were:
1. To derive life table estimates of the probability that,
by a given age, a young person: (i) would have used
an illicit drug; and (ii) will report dependence upon
an illicit drug.
2. To describe the range of illicit drugs used by young
people, and derive life table estimates of the probability
that by age 25 a young person would have used
or become dependent upon a particular kind of drug.
3. To determine the demographic distribution of illicit
drug use and dependence by gender, ethnicity and
education level.
4. To explore the extent to which family and social
factors may contribute to an increased the risk of
illicit drug use and dependence.
Method
Data were collected as part of the Christchurch Health and Development
Study (CHDS), which is a longitudinal study of a birth cohort of
1265 children born in the Christchurch, New Zealand urban region during
mid-1977. This cohort has been studied at birth, 4months, 1 year,
at annual intervals up to age 16, and at ages 18, 21 and 25 years.
Measures
Cannabis and other illicit drug use
At each assessment (15, 16, 18, 21 and 25 years), sample members
were questioned about their use of cannabis and other illicit drugs,
including the age at which they first reported using these drugs, and
the different types of other illicit drugs they had used in each year
from age 14–15 to age 24–25 years. The cohort members were questioned
about their use of a range of illicit drugs, including cannabis,
solvents (glue, petrol, paint); amphetamine-type stimulants (including
methamphetamine and amphetamines); barbiturates; prescription medications
that were illicitly obtained; opiates, including both heroin and
morphine; cocaine (in any form); hallucinogens including ecstasy, LSD
and PCP; and any other substances, primarily plant extracts, including
psilocybin mushrooms and datura. The questions regarding the use
of individual classes of drugs were non-specific to allow comparison
across assessment periods. Reports of cannabis and other illicit drug
use were used to derive life table estimates of the cumulative risk of
cannabis and other illicit drug use (and overall illicit drug use) over the
period 14–25 years.
Cannabis and other illicit drug dependence
In addition, respondents were questioned about symptoms of
cannabis and other illicit drug dependence using questions based on the
generic DSM-IV [6] criteria for substance dependence derived from the
Composite International Diagnostic Interview (CIDI) [7]. This questioning
was not started until age 16 years; thus the earliest estimates
of cannabis and other illicit drug dependence are reported from age
18 years.
Demographic factors
At age 21 years, an assessment of the ethnic identification of M¯aori
members of the cohort was conducted using the 1996 New Zealand
census questions on ethnicity as well as a questionnaire designed by the
Ngai Tahu M¯aori Health Research unit. Fifteen per cent of the cohort
reported M¯aori descent, while 11% reported M¯aori cultural identification.
In this paper those reporting a M¯aori cultural identification were
classified as M¯aori.
At age 18, cohort members were assessed as to the extent of their
educational qualifications. Those who reported having left secondary
school without achieving qualifications were classified as having left
without qualifications (19% of the sample). Gender was recorded at
birth.
Risk factors
To examine predictors of illicit drug use, measures of social, family
and childhood circumstances were considered. These included family
social background, family functioning, individual characteristics, adolescent
behaviours and peer affiliations. Initial analyses revealed that
the following measures were significant predictors of illicit drug use or
dependence:
1. Peer substance use – Assessed on the basis of participant reports
of the extent to which their friends used tobacco, alcohol, or illicit
drugs or had problems resulting from alcohol or illicit drugs,
α =0.69–0.77.
2. Parental history of illicit drug use – Parental illicit drug use was
assessed at age 11 (24.9% of the sample were thus classified) via
parent self-report and scored as a dichotomous measure.
3. Novelty-seeking (age 16) – Assessed at age 16 using the noveltyseeking
items from the Tridimensional Personality Questionnaire
[8], α =0.76.
4. Frequency of cigarette smoking (age 14) – Assessed at age 14 on
a five-point scale ranging from non-smoker to daily smoker via
young person self-report.
5. Frequency of alcohol use (age 14) – Assessed at age 14 via selfreported
number of occasions of alcohol use over the previous
3months via young person self-report.
6. Childhood sexual abuse – Assessed via young person self-report
at ages 18 and 21 for the period up to and including 15 years,
spanning an array of abusive experiences, resulting in a four-level
classification of severity [9].
7. Conduct problems (age 14) – Assessed via parent and child reports
of child behaviour issues at age 14 using items from the Rutter et al.
[10] and Conners [11,12] behaviour scales, and from the Diagnostic
Interview Schedule for Children [13], α =0.90.
Statistical analyses
All analyses were based on all cohortmembers assessed at each point
of observation. Sample sizes were as follows: 15 years (965); 16 years
(953); 18 years (1025); 21 years (1011); and 25 years (1003). These
samples represented between 75% and 81% of the original cohort of
1265 participants and over 85% of study participants resident in New
Zealand at each age.
Rates of cannabis and other illicit drug use by cohort members were
used to calculate life table estimates of cannabis, other illicit drug, and
any illicit drug (either cannabis or other illicit drug) use and dependence,
in order to estimate the cumulative risk of using or being dependent upon
cannabis and other illicit drugs by ages 15, 18, 21 and 25. These life
table estimates were then tested for demographic differences in illicit
drug use and dependence (gender, M¯aori and education level) using a
univariate log-rank test. Finally, proportional hazards regression models
were fitted to the data to identify childhood and family factors that were
predictive of the onset of illicit drug use or dependence.
Results
The development of illicit drug use
Table 1 presents life table estimates of risks of cannabis and other
illicit drug use and dependence over the period from 15 to 25. The table
shows a high level of use of both cannabis and other illicit drugs. By
the age of 25, almost 77% of the cohort had used cannabis and 43.5%
had used other illicit drugs. Overall rates of dependence were relatively
high with nearly one in seven (13.6%) meeting diagnostic criteria for
substance use dependence; 12.5% met criteria for cannabis and 3.6%
met criteria for other drug dependence. The table also shows that there
was a rapid growth in illicit drug use and dependence over the period
from 15 to 18.
Types of illicit drugs used
Table 2 shows the types of other illicit drugs used by the cohort
and the percentage of cases in which each type of drug was used in
cases of dependence by age 25. Other illicit drug use in the cohort was
dominated by hallucinogens, including LSD and ecstasy (36.2%) and
amphetamine-type stimulants (26.9%). However, a substantial minority
had used harder drugs including cocaine (9.1%) and opiates (3.7%).
There was also a high rate of use of other substances, primarily plant
extracts including psilocybin mushrooms and datura.
It will be noted that the percentages of other illicit drugs used exceeds
the percentage (43.5%) of those using any other illicit drugs. This
reflects the fact that those using other illicit drugs tended to use more
than one other illicit drug. Those using other illicit drugs reported a
mean of 2.4 other illicit drugs used by age 25.
Differences in illicit drug use by gender, ethnicity
and education
Table 3 shows life table estimates of the rates for use and dependence
on cannabis and other illicit drugs by age 25, classified by:
(i) gender; (ii) ethnicity; and (iii) education level. The table shows
that:
1. Males were significantly more likely than females to report: (i)
cannabis dependence (p<0.0001); (ii) using other illicit drugs
(p<0.05); (iii) using any illicit drugs (p<0.05); and (iv) dependence
on any illicit drugs (p<0.0001).
2. Cohort members identifying themselves as M¯aori were significantly
more likely than non-M¯aori to report: (i) using cannabis
(p<0.0001); (ii) cannabis dependence (p<0.05); (iii) using any
illicit drugs (p<0.0001); and (iv) dependence on any illicit drugs
(p<0.05).
3. Those cohort members who left school without qualifications were
significantly more likely than those achieving qualifications to report:
(i) using cannabis (p<0.0001); (ii) cannabis dependence
(p<0.0001); (iii) dependence on other illicit drugs (p<0.01); (iv)
using any illicit drugs (p<0.0001); and (v) dependence on any
illicit drugs (p<0.0001).
Risk factors for illicit drug use and dependence
The results above raise issues about the extent to which patterns of
illicit drug use and dependence could have been predicted from factors
present by age 15 years. This issue was explored by fitting proportional
hazards regression models in which the hazards or instantaneous risks
of onset of cannabis and other illicit drug use and dependence by age
25 years were modelled as log-linear functions of a range of social,
childhood and related risk factors. The results of these regression models
are presented in Table 4, which shows parameter estimates, standard
errors, and significance levels for the statistically significant demographic
factors and risk factors for any illicit drug use and dependence.
The table shows that:
1. Illicit drug use was predicted by: (i) male gender (p<0.0001); (ii)
M¯aori identification (p<0.05); (iii) association with substanceusing
peers (p<0.0001); (iv) a parental history of illicit substance
use (p<0.001); (v) novelty-seeking (p<0.0001); (vi) frequency
of cigarette smoking at age 14 (p<0.0001); and (vii) frequency of
alcohol consumption at age 14 (p<0.0001).
2. Illicit drug dependence was predicted by: (i) gender (p<0.0001);
(ii) association with substance-using peers (p<0.0001); (iii) a
parental history of illicit substance use (p<0.05); (iv) childhood
sexual abuse (p<0.0001); (v) novelty-seeking (p<0.0001); and
(vi) conduct problems at age 14 (p<0.05).
The results suggest that the association between education, ethnicity,
and illicit drug use and dependence reported in Table 3 were partially
mediated by the other risk factors shown in Table 4. In particular, after
adjustment for these factors, education level was no longer a predictor
of illicit drug use while ethnicity remained predictive of illicit drug use.
In contrast, both education level and ethnicity were no longer predictive
of illicit drug dependence after risk factors had been taken into account.
However, gender remained a predictor of illicit drug use and dependence
in the proportional hazards regression model, even after control for risk
factors, suggesting that males were more susceptible to use and misuse
of illicit drugs.
Similar proportional hazards regression analyses were carried out
for cannabis use and dependence, and other illicit drug use and
dependence. A similar pattern of findings emerged for cannabis
and other illicit drug use and dependence as were reported.
The results of the fitted regression models for illicit drug use and
dependence are illustrated in Figs 1 and 2, which depict rates of cannabis
and other illicit drug use (Fig. 1) and dependence (Fig. 2) classified by
the number of risk factors present in cohort members. Risk factors were
dichotomized as: (i) present or absent, in the case of (male) gender,
Ma¯ori identification, parental history of illicit substance use, and sexual
abuse; or (ii) the cohort member scoring in the highest decile on the
risk factor measure, in the case of peer substance use, novelty-seeking,
frequency of cigarette smoking and alcohol use, and conduct disorder
at age 14. The dichotomized risk factor scores were summed to give a
total number of risk factors present for each cohort member. The results
for illicit drug use show clear trends in which increased exposure to
risks is associated with increased use of both cannabis and other illicit
drugs. Those with three or more risk factors (38% of the cohort) had
over a 95% chance of using cannabis and a better than 60% chance of
using other illicit drugs. The results for illicit drug dependence show
a similar pattern of increased exposure to risks being associated with
increased dependence. Those with four or more risk factors (11% of the
cohort) had a 50% risk of cannabis dependence and a greater than 15%
risk of dependence on other illicit drugs.
Discussion
This paper has presented a longitudinal description of
patterns of illicit drug use by members of the CHDS
cohort up to the age of 25 years, and an examination of
the risk factors for illicit drug use and dependence among
cohort members. A number of major themes and issues
emerged from the analyses.
The principal findings of this study were of high lifetime
rates of illicit drug use, with nearly 80% of the
cohort using an illicit drug by the age of 25. This high
lifetime rate of illicit drug use is consistent with that
found in other New Zealand studies. Thus, the Dunedin
Multidisciplinary Health and Development Study [14,15]
found that by age 26, 70.1% of cohort members had
used cannabis at some point in their lives (compared
with 76.7% in the current study). Similarly, the 2001
National Drug Use surveys [3] found that nearly 60% of
New Zealanders aged 18–24 reported using cannabis on
at least one occasion. Because the National Drug Use
survey is based on retrospective reports derived from
cross-sectional data, it may underestimate the lifetime
use of illicit drugs by young adults. In comparison with
observed international rates of illicit drug use, drug use
by young New Zealanders appears to be relatively high.
For example, US and European studies suggest rates of
illicit drug use in young people that range from 44% to
55% [16–19]. The high rate of illicit drug use in New
Zealand is largely explained by the high rate of cannabis
use.
As might be expected from high lifetime rates of illicit
drug use, life time rates of illicit drug dependence
in this cohort were comparatively high, with 12.5%
meeting DSM-IV criteria for cannabis dependence and
3.6% meeting criteria for other illicit drug dependence
by age 25. These figures are similar to those reported
by the Dunedin Multidisciplinary Health and Development
Study, who found that 9.4% of the sample had met
DSM-III and DSM-IV criteria for cannabis dependence
by age 26 [15]. There has been growing international
interest in rates of illicit drug dependence, and in particular
cannabis dependence. Comparisons suggest that
Australia and New Zealand tend to have higher rates of
illicit drug dependence, ranging from 12% to 9% [15,20–
22], than the US and Europe, with rates ranging from
3.4% to 2.2% [19,23,24]. Although the precise reasons
for these differences are unknown, it is possible that certain
cultural or social factors unique to Australasia lead
to higher rates of illicit drug dependence in this area. In
the present cohort, high levels of substance use may be
one reason for the observed high levels of dependence,
as suggested by Degenhardt et al. [25].
The results also show that the CHDS cohort members
had experience with awide array of drugs. The most commonly
used drugs, aside from cannabis, were hallucinogens
(36.2%) and amphetamine-type stimulants (26.9%),
with a minority of the cohort using ‘hard’ drugs such as
cocaine (9.1%) and opiates (3.7%). In addition, there was
clear evidence of poly-drug use among those using other
illicit drugs. In this group the average number of different
types of illicit drugs (other than cannabis) used by age 25
was 2.4.
Overall these results reinforce concerns about the apparently
growing utilization of illicit drugs by adolescents
and young people. The findings of this study suggest:
1. The use of illicit drugs by young people has reached
a point where drug use at some point in the life span
is part of normal experience.
2. Although the majority of illicit drug users are occasional
recreational users who do not develop dependence,
nearly one in seven young people develop
dependence on an illicit drug by age 25. In most
cases this dependence involved cannabis.
In agreement with a number of other studies, illicit drug
use and dependence was more common among males,
M¯aori and young people lacking formal educational qualifications
[15,22,26–28].
Subsequent analyses of this cohort suggested that while
gender remained a predictor of illicit drug use and dependence,
the associations between ethnicity and education
level and illicit drug use and dependence reflected the
influence of a series of mediating factors. These factors
included family and childhood factors, peer factors, and
personality factors. Specifically, those factors that were
found to predict illicit substance use and dependence
included having parents who used illicit drugs, experiencing
sexual abuse as a child, affiliating with substanceusing
peers during early adolescence, cigarette smoking
and alcohol consumption by age 14, novelty-seeking behaviours
and conduct problems at age 14. Examination
of the role of these factors in the development of illicit
drug use and dependence suggests a cumulative risk
model in which risks of use and dependence increased
with increasing exposure to risk factors in childhood and
adolescence.
Although the present study provides an overview of
illicit drug use and dependence and the correlates of such
use and dependence, the findings are subject to a number
of caveats.
1. Measurement – First, all measurements were based
on self-report data, and the accuracy of the reports
depends upon the willingness of respondents to
disclose illicit drug use and dependence. It is possible
that this limitation may have led to some underreporting
of illicit drug use and dependence, so the
results of this study should best be interpreted as
giving lower limit estimates of the actual incidence
of illicit drug use and dependence among the CHDS
cohort.
2. Sampling – This paper is based on the results for
a cohort born at a specific point in time and in a
specific geographic region, and measured at specific
ages. The extent to which these findings can be generalized
to other cohorts in other regions of New
Zealand or elsewhere is unclear. In particular, there
has been concern on the part of many about the increasing
use of illicit drugs by adolescents, and it
may be that findings from this study have underestimated
the problem of the use of illicit drugs in the
contemporary adolescent population.
These concerns notwithstanding, the present study suggests
a disturbingly high level of use of, and dependence
on, illicit drugs by young people in New Zealand,
with particularly high rates of cannabis use. The findings
should serve to alert psychiatrists and others dealing
with this population that issues regarding illicit drug use
are perhaps more pervasive than previously believed, and
that more attention should perhaps be given to the role
of cannabis in the development of drug problems. Recent
advances in brief interventions for cannabis and other
substance dependence [29–31] would suggest that, although
the problems of drug use and dependence may be
underestimated, they may indeed be tractable.

Mental symptoms, psychotropic drug use and alcohol consumption in immigrated middle-aged women. The Women’s Health in Lund Area (WHILA) Study

noreply@blogger.com (Landrogek) — Mon, 25 Feb 2008 17:57:00 +0000

This study aims to analyse mental symptoms, psychotropic drug use and alcohol consumption,
in immigrant women born in Finland, the other Nordic countries, Eastern Europe, Western
Europe and countries outside Europe, compared with Swedish-born women, and furthermore,
to study if age at immigration may have an influence. All women (n /10,766) aged 50 59 years
and living in the Lund area of southern Sweden received a postal invitation to a health survey
named the Women’s Health in Lund Area; 64.2% (n /6917) participated. The participants
answered a questionnaire including prevalence of mental symptoms during the past 3 months,
regular use of psychotropic drugs, alcohol consumption during an average week, country of
birth and age at immigration. Severe mental symptoms were more common among most
immigrant groups compared with native Swedes, but the association to country of birth was not
significant after adjustment for possible confounders. Regular use of hypnotics was more
common among Nordic immigrants only (odds ration). East European and non-
European immigrants less often were alcohol consumers . Heavy
drinking was more common among non-Nordic immigrants who immigrated at a younger age
than at an older age. Furthermore, it was found that although East European and non-European
immigrants had a higher educational level, they were less often gainfully employed compared
with native Swedes. In middle-aged women, country of birth as well as age at immigration are
important factors to consider in relation to alcohol consumption, but these factors may be of
less importance considering mental health.

During the last decade, alcohol consumption and
long-term sick-leave due to mental diagnoses have
increased dramatically in the Swedish population, particularly
among women (1, 2). Alcohol consumption and
mental health problems in immigrated middle-aged
women have been insufficiently studied, but increased
knowledge is of vital interest, since Sweden, like many
European countries, is turning into a multi-ethnic
society. In general, immigrants may be considered a
vulnerable group as they face a number of stressors such
as acculturative, socio-economic and minority stress.
In a female population 50-59 years old, we have
previously investigated mental symptoms and alcohol
consumption, and found that immigrants more often
had severe mental symptoms but less often drank
alcohol compared with native Swedes (3, 4). In these
studies, we only analysed whether the woman was an
immigrant or not. In the present study, we will further
investigate the findings by focusing on the immigrated
woman’s country of birth and age at immigration.
This study aims to analyse mental symptoms, psychotropic
drug use and alcohol consumption in immigrant
women born in Finland, the other Nordic countries, East
Europe, West Europe and countries outside Europe,
compared with Swedish-born women, and in addition
to study if age at immigration may have an influence.
Material and Methods
Participants
All women (n /10,766) aged 50 59 years, born between
2 December 1935 and 1 December 1945, and by 1
December 1995 living in the Lund area of southern
Sweden (172,005 inhabitants) were invited to the Women’s
Health in Lund Area Study (WHILA). This study
is based on a self-administered questionnaire, which was
received by mail, filled out at home and returned at a
medical examination where a nurse/midwife assisted to
rule out information bias; an interpreter assisted when
needed. The examinations took place from 2 December
1995 until 3 February 2000. A total of 6917 women
(64.2%) participated, among whom 601 (8.7%) were
immigrants. An attrition analysis has been presented
previously (3). Informed consent was obtained from all
participants. The ethics committee at Lund University
approved the study.
We lack information about country of birth among
non-participants, but according to Statistics Sweden, of
all women aged 50 59 years and in 1995 living in the
Lund area, 89.4% (n /9649) were native Swedes, 3.5%
(n /379) born in another Nordic country, 5.5% (n /595)
born in another European country and 1.5% (n /167)
born outside Europe. In comparison with our figures
(presented under Results), Nordic and non-European
immigrants were representative, whereas European immigrants
participated less often (PB/0.001).
Questionnaire
NATIVE COUNTRY
Based on stated country of birth the women were
divided into six categories: ‘‘native Swede’’, ‘‘Finnish
immigrant’’, ‘‘Nordic immigrant’’ (i.e. Denmark, Iceland
and Norway), ‘‘East European immigrant’’ (also
including former Soviet Union), West European immigrant
(also including countries in southern Europe) and
‘‘non-European immigrant’’.
AGE AT IMMIGRATION
Based on their age at immigration to Sweden the
immigrated women were divided into: B/18 years (lowest
quartile), 18 34 and ]/35 years old (highest quartile).
MENTAL SYMPTOMS
The Gothenburg Quality of Life instrument was used to
measure prevalence of 10 mental and 19 physical
symptoms. The women answered ‘‘yes’’ or ‘‘no’’ as to
whether the symptom had troubled her during the past
3 months (5). Based on the sum of mental symptoms, we
classified severity of mental symptoms: ‘‘absent/slight’’
(0 1 symptom, lowest quartile), ‘‘moderate’’ (2 6
symptoms) and ‘‘severe’’ (7 10 symptoms, highest
quartile).
PSYCHOTROPIC DRUG USE
The women reported what medications they regularly
use. In this paper, we examined their use of the
psychotropic drugs*anxiolytics, hypnotics and antidepressants.
ALCOHOL CONSUMPTION
The women reported the quantity (glass/bottles specified
in centilitres) of wine, beer and liquor respectively that
they drink during an average week, or chose the option
‘‘no alcohol’’. We converted total alcohol intake into
grams of alcohol and created four categories: none, low
(1 83 g), moderate (84 167 g) and heavy (]/168 g) (4).
SOCIAL SITUATION
The women stated household composition (with partner,
alone, with partner and child/ren, single parent or with
parent/other), highest level of education (comprehensive
school, upper secondary school or university education),
employment status (full-time/part-time work, unemployed,
disability pension, long-term sick leave or
housewife) and if she visited friends at least once a
month.
PHYSICAL HEALTH
The women stated whether they use hormone replacement
therapy. As described above the prevalence of 19
physical symptoms was asked for. Based on the sum of
physical symptoms we classified severity of physical
symptoms: ‘‘absent/slight’’ (0 2 symptoms, lowest quartile),
‘‘moderate’’ (3 7 symptoms), and ‘‘severe’’ (8 19
symptoms, highest quartile).
Statistics
Calculations were performed using the computer software
SPSS 12.0. The chi-square test was used to analyse
differences in proportions and when required Fishers
exact test was used. P-values B/0.05 were considered
statistically significant. In calculation of employment,
old-age pensioners and students were
excluded.
When analysing the country of birth, 21 women were
excluded as they stated being born abroad but did not
state the country. Each immigrant group was compared
with native Swedes (Table 1).
Four separate multivariate logistic regression analyses
were performed: severe mental symptoms vs.
absent/slight symptoms ; use of hypnotics vs. no use ; use of antidepressants (n /325)
vs. no use ; and non-drinking (n ow/moderate/heavy drinking (n 4901). In the first
three analyses, we adjusted for age, alcohol consumption,
household, level of education, employment, visiting
friends, physical symptoms, and use of hormone replacement
therapy in the first block, and country of birth in
the second block. In the last-mentioned analysis (nondrinking)
we adjusted for age, severity of mental
symptoms, use of anxiolytics, use of hypnotics, use of
antidepressants, household, level of education, employment,
visiting friends, physical symptoms, and use of
hormone replacement therapy in the first block, country
of birth in the second block. Hosmer and Lemeshow
tests were performed: 0.816-0.843.
When analysing the influence of age at immigration,
64 immigrants were excluded: 21 that did not state
country of birth and 43 that did not state when they
immigrated. Due to the small number of women in each
age group, Finnish and Nordic immigrants were merged
into ‘‘Nordic immigrants’’ and East and West European
immigrants into ‘‘European immigrants’’. Age at immigration
within Nordic, European and non-European
immigrants respectively was compared (Table 2).
Results
East European, West European and non-European
immigrants more often were troubled by severe mental
symptoms compared with native Swedes; Nordic immigrants
more often used hypnotics and antidepressants,
and non-European immigrants significantly more often
were non-drinkers of alcohol (Table 1).
All immigrant groups except Nordic immigrants
differed regarding the social situation in comparison
with native Swedes. Finnish immigrants more often lived
alone, 27% vs. 18%, or as single parents, 8% vs. 4% (PB/
0.01, 4 df), were disability pensioners, 20% vs. 8%
(PB/0.01, 4 df), and less often visited friends, 18% vs.
8% (PB/0.001, 1 df). East European immigrants more
often had university education, 62% vs. 34% (PB/0.001,
2 df), were disability pensioners, 14% vs. 8%, or housewives,
6% vs. 2% (PB/0.001, 4 df). West European
immigrants more often lived alone, 25% vs. 18%
(PB/0.05, 4 df), had upper secondary school education,
51% vs. 41% (PB/0.05, 2 df), and less often visited
friends, 18% vs. 8% (PB/0.001, 1 df). Non-European
immigrants differed most; they more often lived alone,
30% vs. 18%, as single parents, 16% vs. 4%, or with
parent/other, 4% vs. 1% (PB/0.001, 4 df). They more
often had university education, 50% vs. 34% (PB/0.01,
2 df), were unemployed, 15% vs. 4% (PB/0.001, 4 df),
and less often visited friends, 15% vs. 8% (PB/0.05, 1 df).
All immigrant groups except Nordic immigrants more
often were troubled by severe physical symptoms in
comparison with native Swedes; Finnish immigrants,
28% vs. 17% (PB/0.01, 2 df), East European immigrants,
35% vs. 17% (PB/0.001, 2 df), West European immigrants,
29% vs. 17% (PB/0.001, 2 df), and non-European
immigrants 33% vs. 17% (PB/0.001, 2 df).
Furthermore, non-European immigrants less often
used hormone replacement therapy, 24% vs. 45% (PB/
0.001, 1 df).
Four separate multivariate logistic regression analyses
were performed as described in the Statistics section.
Independently of age and other possible confounders,
Nordic immigrants were associated with use of hypnotics
,
East European and non-European immigrants were
associated with non-drinking of alcohol . East European, West
European and non-European immigrants did not remain
associated with severe mental symptoms, nor did Nordic
immigrants remain associated with use of antidepressants.
Age at immigration
Discussion
In a total population of women aged 50 59 years and
living in a geographically defined area, we analysed
whether mental symptoms, psychotropic drug use and
alcohol consumption were associated with country of
birth and age at immigration.
There are some weaknesses in the study*primarily
that the immigrant women were divided into rather
broad categories based on their country of birth. The
categorization could lead to inaccurate generalizations,
but was necessary due to the limited number of
participants from different countries (except from Finland).
To analyse every country specifically could lead to
inaccurate generalizations, as each country contains a
heterogeneous group of ethnic groups, social classes,
religions and cultures. Another weakness in the study
was that the woman’s reason for immigration was not
requested. The major types of immigration to Sweden
are labour migration and forced migration, and these
characteristics have varied between countries and over
time (6). Tentatively we can assume that Finnish, Nordic
and West European immigrants are labour migrants (as
only three women from former-Yugoslavia had immigrated
after the outbreak of war), whereas East European
and non-European immigrants are refugees.
Consequently, the results in this study, as for most
studies of immigrants, must be interpreted with caution.
In the present study, we found that East European,
West European and non-European immigrants were
more often troubled by severe mental symptoms compared
with native Swedes, but the association to country
of birth was not statistically significant after control for
possible confounders. Several studies have stressed
poorer mental health among immigrants compared to
native Swedes in terms of psychosomatic complaints,
psychological distress, longstanding psychiatric illness,
attempted suicide and suicide . European immi-
grants B/18 years at immigration were less often
troubled by severe mental symptoms. Young age at
migration has been found favourable for mental health,
suggesting that immigrants may overcome the nativity
disadvantages found for emotional distress with increased
duration of residence (12).
When an immigrant patient seeks help for mental
symptoms, it may well be easier for the general practitioner
to prescribe psychotropic drugs than to offer
psychosocial or psychotherapeutic treatment. Hjern
concludes that immigrants’ higher consumption of
sedatives and hypnotics indicates a differential treatment
of minor psychiatric disorders of members of ethnic
minorities in the Swedish healthcare system (13). In our
study, however, we found that only Nordic immigrants
used psychotropic drugs more frequently. This is an
interesting finding, which warrants further investigation.
In contrast to prior Swedish studies, we did not find that
non-European immigrants had a higher use of psychotropic
drugs (9, 13, 14).
Furthermore, we found that non-European immigrants
were more often non-users of alcohol, which
was independent of age and other possible confounders.
Many non-European immigrants were born in countries
where female drinking is uncommon. Conceivably, some
were Muslim who tend to refrain from alcohol. Furthermore,
East European immigrants more often were nonusers,
but this association was rather weak. Alcohol
consumption did not differ between Finnish immigrants
and native Swedes. Prior studies have found more
alcohol-related problems, higher hospital admission
because of an alcohol-related disorder and higher
alcohol-related mortality among female Finnish immigrants
(15 17). Among European and non-European
immigrants, subjects ]/35 years old at immigration were
more often non-drinkers, whereas younger women were
more often heavy-drinkers. When immigrants get assimilated
to their new society their alcohol consumption
usually increases to approximate that of the native
population (18 21). However, our results suggest that
for women a young age at migration may involve an
increased risk of heavy drinking in their middle age.
That Lund is a pronounced university town can
explain the generally high level of education amongst
participants, which may be one reason for the lack of
agreement with results in prior studies. Another reason
may be that none of those studies have focused on
middle-aged women.
Another finding was that although East European
and non-European immigrants had a higher level of
education than native Swedes, they were less often
gainfully employed. A similar result was found in a
Swedish study of younger immigrant women (7). The
reason for this is likely multi-factorial and needs further
attention. We found that all immigrant groups, except
the Nordic, differed from native Swedes regarding their
social situation. Non-European immigrants had the
poorest social situation. A report from Statistics Sweden
shows that labour migrants from wealthy countries soon
attain the same standard of living as native Swedes,
whereas many refugees never do (22).
To sum up the findings in this study; severe mental
symptoms were more common among most immigrant
groups compared with native Swedes, but the association
to country of birth was not significant after adjustment
for possible confounders. Regular use of hypnotics was
more common among Nordic immigrants only. East
European and non-European immigrants less often
consumed alcohol. Heavy drinking was more common
among non-Nordic immigrants who immigrated at a
younger age than at an older age. Although East
European and non-European immigrants had a higher
educational level they were less often gainfully employed
compared with native Swedes.
We conclude that in middle-aged women country of
birth as well as age at immigration are important factors
to consider in relation to alcohol consumption, but these
factors may be of less importance considering mental
health.

Club Drug Use in Los Angeles Among Young Men Who Have SexWith Men

noreply@blogger.com (Landrogek) — Sat, 23 Feb 2008 19:22:00 +0000

Little is known about young men who have sex with men’s use of club drugs and the risk
factors associated with such use. A structured survey was administered in 2005 to 496
young men who were 18–22 years old (40% were 18–19 years old); self-identified as
with a same-sex sexuality (83%), bisexual (16%), and/or had had sex with a man (97%);
Caucasian (35%), African American (24%), and Latino of Mexican descent (40%).
Subjects were recruited from gay-identified venues in Los Angeles, California, using a
venue-based probability sampling design. Descriptive statistics revealed a high prevalence
of drug and club drug use. Regression analyses revealed risk factors associated
with recent club drug use, including place of residence, religiosity, disclosure of sexuality
to family, frequency of attendance at bars/clubs, and involvement in sexual exchange
and street economy. Limitations and implications of this research are discussed.
Introduction
While it is now well understood that most adolescents will experiment with alcohol and
drugs at some point during their teens (Arnett, 2000), there is also considerable evidence that
young men who have sex with men (YMSM)1 are at particularly high risk for drug use. For
manyYMSM,adolescence is a time of rejection from family and friends, stigmatization, and
social isolation. While connectedness with family has repeatedly been found to be highly
protective against drug use and other risky behaviors among young people (Flaherty and
Richman, 1986; Kobak and Sceery, 1988; Sarason, Pierce, Bannerman, and Sarason, 1993;
Sneed, Morisky, Rotheram-Borus, Ebin, and Malotte, 2001; Sroufe and Fleeson, 1986),
YMSM often find themselves feeling disconnected and isolated from their families because
of their sexuality. Moreover, the struggle to develop and integrate a positive adult identity,
a primary developmental task for all adolescents, becomes an even greater challenge for
YMSMgiven the disapproval, discrimination, and homophobiamany experience (D’Augelli
and Herschberger, 1993; Gonsiorek, 1988; Hetrick and Martin, 1987; Hunter and Mallon,
1999; Ryan and Futterman, 1997; Savin-Williams, 1989, 1990b; Telljohann and Price,
1993; Uribe and Harbeck, 1992). YMSM may resist disclosure of their sexuality out of
fear of rejection by peers or family members (Gonsiorek, 1988; Savin-Williams, 1989,
1990b). Among those who have “come out,” families may not react well to this disclosure
(Telljohann and Price, 1993), with negative reactions ranging from tolerance, rather than
active support of the individual to, extreme hostility, abuse, and violence (Hunter, 1990;
Remafedi, 1987). These negative reactions may in turn result in a range of health and mental
health problems (Martin and Hetrick, 1988; Savin-Williams, 1990a; Savin-Williams and
Lenhart, 1990), including alcohol and drug use. To ease their sense of isolation, these youth
may seek out and begin to spend time in gay venues, such as bars or clubs, where they may
find acceptance, but also be introduced to illicit drugs, including club drugs.
To date, little research has been conducted to examine the impact of these experiences—
i.e., the impact of coming out to family and friends, feeling acceptance and/or rejection from
family and friends—on YMSM’s use of drugs and involvement in risk behaviors (Ryan and
Futterman, 1997). The limited research that has been conducted suggests that YMSM are
significantly more likely than heterosexual youth to report lifetime use of alcohol and
drugs, including injectable drugs, as well as report use of marijuana and cocaine before
13 years of age (Wolitski, Valdiserri, Denning, and Levine, 2001). Risk factors associated
with high levels of substance use include a history of childhood sexual abuse (Hughes
and Eliason, 2002), stressful life events (Rosario, Schrimshaw, and Hunter, 2004), gayrelated
verbal harassment and discrimination (Rosario, Rotheram-Borus, and Reid, 1996),
and involvement in gay-related social events (Rosario et al., 2004). Unfortunately, the vast
majority of studies conducted to date with YMSM have been descriptive in nature and
conducted with small, nonrepresentative samples of convenience. The one exception is the
Young Men’s Survey, a large-scale study conducted in the mid-1990s with 15- to 22-yearold
YMSM in seven U.S. cities (Valleroy et al., 2000). Findings from this study revealed
a high prevalence of lifetime, recent, and frequent illicit drug use, including stimulants
such as cocaine and amphetamines. Risk factors found to be associated with drug use in
this sample included race/ethnicity (with Caucasian youth being at increased risk), sexual
identity (with youth who identified as bisexual and heterosexual being at increased risk),
disclosure of sexual identity (with nondisclosure associated with increased risk), history of
sexual abuse, and history of homelessness. No subsequent research has been conducted to
examine YMSM’s drug use patterns in light of more recent trends in the availability and
popularity of illicit drugs.
In contrast to the limited research that has been conducted to date with YMSM, considerable
research has been conducted to examine the drug use patterns of older adult men
who have sex with men (MSM), suggesting that MSM may have as much as a sevenfold
increase in illicit drug use when compared to a nationally representative sample of single
urban men (Woody et al., 2001). Risk factors found to be associated with drug use among
MSM include a history of forced sex and/or childhood sexual abuse (Ellickson, Collins,
Bogart, Klein, and Taylor, 2005; Kaukinen, 2002), attendance in gay bars or nightclubs
(Waldo, McFarland, Katz, MacKellar, and Valleroy, 2000), and internalized homophobia
(Malyon, 1982; Nungesser, 1983; Shidlo, 1994; Swadi, 1999).
Recent studies have begun to examine MSM’s use of club drugs, particularly within the
context of MSM’s involvement in HIV risk behaviors (Halkitis, Parsons, and Stirratt, 2001;
Koblin et al., 2003; Reback, 1997; Reback, Larkins, and Shoptaw, 2004; Stall and Ostrow,
1989; Thiede et al., 2003; Weber et al., 2003). Generally speaking, club drugs refer to a
category of drugs that are commonly used at clubs, raves, or dance parties, including cocaine,
methamphetamine, ecstasy, GHB, and ketamine. Club drugs in general, but stimulants in
particular, are believed to be responsible for the increased prevalence of sexually transmitted
infections (STIs) reported among MSM since the late 1990s (Eichenthal, 2001; Guss, 2000;
Halkitis, Fischgrund, and Parsons, 2005; Halkitis et al., 2001; Halkitis, Parsons, andWilton,
2003; Patterson and Semple, 2003; Reback et al., 2004). Methamphetamine, one of the
most commonly used club drugs (Finnerty, 2003) has been found to put MSM at increased
risk for engaging in HIV risk-related sexual behaviors and infection (Eichenthal, 2001;
Stall et al., 2001). Methamphetamine is believed to encourage risky sexual behaviors by
intensifying and prolonging sexual encounters, increasing the subjective pleasure of sex
(Guss, 2000; Halkitis et al., 2005, 2001, 2003; Patterson and Semple, 2003), increasing a
sense of euphoria and confidence, and encouraging impulsivity that may in turn lower one’s
inhibition to engage in unprotected sex (Halkitis et al., 2003; Kurtz, 2005; Purcell, Ibanez,
and Schwartz, 2005). Despite rising concerns about club drug use among MSM, little is
known about YMSM’s use of these drugs.
In this article, we report the prevalence of illicit drug use and correlates of recent club
drug use among a large and ethnically diverse sample of YMSM recruited from gay venues
in Los Angeles, California, using a venue-based probability sampling design. The research
received Institutional Review Board approval.
Methods
Study Sample and Sampling Design
A total of 496 subjects were recruited into the Health Young Men’s (HYM) Study between
February and December of 2005.2 Young men were eligible to participate in the
study if they were 18–22 years old; self-identified as gay, bisexual, or uncertain about
their sexual orientation and/or reported having had sex with a man; self-identified as Caucasian,
African American, or Latino of Mexican descent; and a resident of Los Angeles
County with no expectation of living outside the county for at least 6 months following
recruitment.
Young men were recruited at public venues using the venue-based probability sampling
design developed by the Young Men’s Study and later modified by the Community
Intervention Trials for Youth study (MacKellar, Valleroy, Karon, Lemp, and Janssen, 1996;
Muhib et al., 2001). Public venues included bars, coffee houses, parks, beaches, and hightraffic
street locations where YMSM spend time or hang out; social events such as a picnic
or baseball game sponsored by an agency or organization that serves YMSM; and special
events such as gay pride festivals. Enumerations of young men attending these types
of venues were first conducted at different days and times. Based on these enumerations,
sampling frames were constructed of specific 4-hour time periods from 36 venues where
a minimum of eight eligible men might be encountered for further information about the
study design and sampling methods).
Recruitment Procedures
Three to four researchers conducted 4-hour sampling events in accordance with monthly
sampling calendars. Young men who entered the venue and appeared to be eligible for
the study were systematically counted (using a “clicker”) and invited to complete a brief
screening instrument to determine eligibility. Young men were counted or approached only
once, regardless of whether they entered a venue multiple times. If a young man was
found to meet the study criteria, he was provided with a detailed description of the study.
The screening instrument was administered in English and Spanish. Informed consent and
contact information was obtained from those who agreed to participate. All interviews were
scheduled within two weeks of the recruitment date.
Survey Instrument
The surveywas administered in both English and Spanish using computer-assisted interview
(CAI) technologies and an on-line testing format (Kissinger et al., 1999; Ross, Tikkanen,
and Mansson, 2000). The CAI software used in this study incorporated sound files, which
allowed the respondent to silently read questions and/or listen to the questions read through
headphones and enter their responses directly into the computer. Administration of the
survey required on average 1 1/2 hours. Analyses were performed to examine the prevalence
of illicit drug use, as well as the relationship between the following demographic
and psychosocial variables (independent variables) and recent club drug use (dependent
variable):
Demographic Variables. Participants were asked to report their age: race/ethnicity; place
of birth; immigration status; current place of residence; employment status; whether they
are attending school; had ever been homeless; had ever “exchanged a sexual act or favor
for something like money, drugs, or a place to stay”; and had ever participated in the street
economy (e.g., selling/running drugs, prostitution, panhandling).
Sexuality. Participants were asked which sexual identity they most identified with (e.g., gay,
queer, bisexual, same gender loving, straight). Sexual attraction was measured by asking
participants “How much are you sexually attracted to males/females”; it was then recoded
to create a new 3-level nominal variable: sexually attracted to males only, to females only,
or to both males and females. Disclosure of sexuality was measured by asking participants
to report how many of their family, best/closest friends, and other friends about their sexual
identity, attractions, or behavior.
Social Support. The Multidimensional Scale of Perceived Social Support (Zimet, Dahlem,
Zimet, and Farley, 1988) is a 12-item scale that was used to measure perceived support from
family and friends. A total score was calculated by summing the items. Participants were
said to have high family/peer support if they had a score less than 7 (lower 25th percentile)
and high friend/peer support if they had a score less than 5 (lower 25th percentile).
Religiosity. Religiosity was measured by asking participants how religious they consider
themselves (Sheeran, Abrams, Abraham, and Spears, 1993). Responses were recoded to
create a dichotomized variable of religiosity: very or somewhat religious vs. not very or not
at all religious.
Sexual Abuse. Participants were asked if they had ever been sexually abused or assaulted,
either as a child or as an adult.
Depression. Depression was measured using the 20-item Center for Epidemiologic Studies
Depression (CES-D) Scale (Radloff, 1977) whereby participants were asked to report
whether they had experienced depressive symptoms within the past week. A total score
was calculated by summing the items, and cut-points were also created based on previous
research conducted with MSM (Ryff and Keyes, 1995; Stall et al., 2001); a score of 6 to 21
was considered distressed, a score greater than 22 was considered depressed.
Stressful Life Events. Stressful life events were measured by asking participants if they had
experienced one or more stressful events during the previous 3 months (Wills, 1986). A
total score was calculated by summing the number of items checked; a score of 9 or more
(top 75th percentile) was considered to be highly stressed.
Bar/Club Attendance. Attendance at a gay bar or club was assessed by asking participants,
“How often in the last three months did you go to a gay bar or club?” (Vanable, McKirnan,
and Stokes, 1998).
Alcohol and Illicit Drug Use. Participants were asked about their lifetime, past 3-month, and
past 30-day use of tobacco, alcohol, and illicit drugs; their involvement in injection drug use;
and the number of days within the past 30 days that they had used each drug. Club drugs were
defined to cocaine, crystal/methamphetamine, ecstasy, poppers, GHB, Ketamine, and other
forms of speed. Also assessed was use of prescription drugs obtained without a physician’s
order, including anti-anxiety (e.g., Valium, Xanax), depressants (e.g., Nembutal, Seconal),
anti-depressant/sedative, opiate/narcotic (e.g., Vicodin, Oxycontin, Codiene), and attention
deficit disorder medications. Other drugs assessed included marijuana, crack, LSD, PCP,
heroin, and mushrooms.
Statistical Analysis
All statistical analyses were conducted using STATA V. 9 (StataCorp, 2005). Cronbach’s
alphas were also computed for each scale, as reported in Table 1. Descriptive statistics,
such as frequencies, percentages, means, medians and ranges, were next used to tabulate
the sample demographics. These statistics, along with a priori knowledge of the literature,
were used to investigate potential cut-points for continuous variables and groupings for
categorical variables to address sample size complications and to create meaningful categories.
Univariate (unadjusted) and multivariate (multiple) logistic regression were used
to examine the relationship between each of the theoretically relevant independent (demographic
and psychosocial variables) and dependent (past 3-month club drug use) variables.
For each independent variable, the odds of club drug use in the past 3 months is reported,
along with 95% confidence intervals (CI), to respectively measure associations between
dependent and independent variables and the precision of these estimates. Unadjusted odds
ratios were calculated to test appropriate categories and cut-points of independent variables
as well as to identify candidate variables for inclusion into the multivariate model. The
adjusted odds ratios estimated through multiple logistic regression controlled for multiple
variables simultaneously to account for potential confounded relationships.
To select the best set of risk variables for the multiple logistic regression model, forward
stepwise regression was used including variables with a p value of 0.15 and 0.20. This criteria
is less stringent than the standard p = 0.05 and thus has more power to detect potential
confounding effects (Kleinbaum, Kupper, and Morgenstern, 1982; Rothman, 1998). After
examining correlations, there appeared to be no evidence of collinearity between variables
entered into the stepwise model. Overall model fit was assessed by the Hosmer-Lemeshow
goodness of fit test. Automated stepwise procedures have been recommended to identity
the most parsimonious set of variables to predict the outcome (e.g., drug use; Kleinbaum,
1994). To test the selected model, a confirmatory analysis was further conducted by examining
changes in the estimates and confidence intervals when manually adding candidate
variables to build a multivariate model (Rothman, 1998). Using both techniques, the same
set of variables was selected for the final multivariate model.
Results
Sample Demographic Characteristics
As summarized in Table 2, a total of 496 YMSM were enrolled in the study during the first
11 months of recruitment, including 175 (35%) Caucasian, 121 (24%) African American,
and 200 (40%) Latino YMSM of Mexican decent. The average age was 20.1 years, with
40% of the sample being 18–19 years of age. Eighty respondents (16%) reported having
been born outside of the United States, while over half (54%) of the respondents reported
living at home with their family at the time of their baseline interview. Twenty-one percent
reported being in school while an additional 27% reported both attending school and being
employed; only 14% reported being neither in school nor employed. Forty-three percent
reported being very or somewhat religious, while 57% reported not being very religious
or not at all religious. Of those who reported being religious, 71% reported that they were
affiliated with the same religion that they had participated in while growing up, with the
vast majority being Catholic (34%) or Protestant (33%).
Given the study enrollment criteria, 83% self-identified as homosexual, gay, or some
other same-sex sexual identity (e.g., “same gender loving”), 16% self-identified as bisexual,
and 1% self-identified as straight or heterosexual. In contrast, 70% of the sample reported
being sexually attracted exclusively to males, 28% reported being sexually attracted to both
males and females, and 1% reported only being sexually attracted to females. Remarkably,
20% reported having a history of sexual abuse/assault, 16% reported having traded a sexual
act or favor for something, and 7% reported a history of homelessness.
Psychosocial Variables
The vast majority of respondents reported that they had disclosed their sexuality/identity to
their family and friends, with only 15% reporting that none of their family members knew
about their sexual orientation. Similarly, nearly all of the respondents reported that most
or all of their best/close friends and other friends knew about their sexuality (91 and 71%,
respectively).
Respondents reported high levels of support from both their family and friends. They
also reported having had on average seven stressful life events during the previous 3 months,
with the most common stressful events being family arguments (58%), financial difficulties
(49%), arguments with a partner (44%), relationship with partner ending (37%), and
problems/difficulties with a close friend (49%). Additionally, 21% reported symptoms of
sufficient severity to suggest depression as assessed by the CES-D, and 18% of respondents
reported symptoms suggesting they were distressed.
Club and Other Illicit Drug Use
Within this sample, 69% of respondents reported having ever used an illicit drug (49% if
marijuana is not included in this analysis). Of those who had ever used an illicit drug, 72%
reported use within the previous 3 months and 62% within the past 30 days. As presented
in Table 3, 90% of the sample reported lifetime use of alcohol, 64% reported lifetime use
of marijuana, 40% reported lifetime use of club drug (23% reported use of cocaine, 20%
reported use of crystal methamphetamine, 21% reported use of ecstasy), and 26% reported
lifetime use of a prescription drug without a physician’s order (14% reported use of an antianxiety,
17% reported use of an opiate/narcotic). In contrast, lifetime use of street drugs,
such as crack (5%), LSD (5%), and heroin (2%) was low. Only 2% reported having ever
injected a drug. The mean age of initiation of alcohol and marijuana was 16.5 and 16.8,
respectively, with the mean age of initiation of any club drug being 17.8 years, the mean
age of initiation of any prescription drug use without a physician’s order being 17.6, and
the mean age of initiation of injection drug use being 17 years.
A comparison of the prevalence of lifetime use reported by HYM Study subjects with
lifetime use reported by a nationally representative sample of high school seniors assessed
as part of the Monitoring the Future (MTF) study (Johnston, O’Malley, Bachman, and
Schulenberg, 2006) and a nationally representative sample of YMSM, ages 15 to 22 years,
assessed as part of the Young Men’s Survey (Valleroy et al., 2000), is provided in Table 4.
These comparisons provide further evidence that our study sample, like similar YMSM
interviewed 10 years ago, reported considerably higher rates of illicit drug use than the
general population of adolescents. As presented in this table, nearly half of the HYM
subjects (49%) reported lifetime use of an illicit drug other than marijuana as compared to
a little over a quarter (27%) of high school seniors. Moreover, the prevalence of lifetime
club drug use among HYM subjects was considerably higher than use reported among high
school seniors, and yet comparable to lifetime use reported by YMSM from the YMS study.
The prevalence of recent drug use was also high, with 56% of those who had ever used
a club drug reporting club drug use within the past 3 months, most of those who reported
club drug use within the past three months, most (46%) reported use of cocaine, followed by
crystal, ecstasy, and poppers/nitrates (39, 33 and 26%, respectively). While a high percentage
of the sample reported lifetime and recent use of illicit drugs, respondents reported infrequent
use during the previous 30 days; the median number of days that respondents reported drug
use ranged from 1 day during the past month for some prescription drugs to 3.5 days during
the past month that marijuana was used.
Univariate Analyses
Simple odds ratios demonstrating crude relationships between the independent variables
and recent club drug use (i.e., past 3 months) are presented in Table 5. These odds ratios
revealed that respondents at greatest risk for recent club drug use included those who: were
older (OR = 1.86, 95% CI = 1.10, 3.15); had a history of homelessness (OR = 3.2, 95%
CI = 1.59, 6.46); had ever engaged in sex exchange (OR = 4.97, 95% CI = 3.0, 8.23) or
had ever participated in the street economy (OR = 5.08, 95% CI = 3.19, 8.10); were not
in school nor employed (OR = 2.37, 95% CI = 1.12, 4.99); and who frequented a gay
bar/club several times a week (OR = 1.84, 95% CI = 1.09, 3.08). Moreover, respondents
who lived in their own apartment (OR = 1.68, CI = 1.07, 2.65) or with a friend/partner (OR
= 2.48, CI = 1.27, 4.82) were significantly more likely to report recent club drug use than
respondents living at home with their family. In contrast to the literature, respondents who
had disclosed their sexuality to all or most of their family members were also at greater risk
for recent club drug use (OR = 2.30, 95% CI = 1.14, 4.63). Respondents at significantly
less risk for recent club drug use were those who were African American (OR = 0.53, 95%
CI = 0.30, 0.93) or Latino (although not significant, there was a suggested association with
an OR = 0.64, 95% CI = 0.40, 1.04); and who reported being very or somewhat religious
(OR = 0.60, 95% CI = 0.39, 0.94). There was a suggested association between recent
club drug use and the number of stressful life events, with respondents who reported 9 or
more stressful events being more likely to report recent club drug use than respondents
who reported 8 or less stressful events (OR = 1.74, 95% CI = 1.12, 2.69). Other variables
not found to be significantly associated with recent club drug use were immigration status,
sexual attraction, family support, peer support, disclosure of sexuality to peers, and history
of sexual abuse/assault.
Multivariate Analyses
The final fitted model using forward stepwise procedures and adjusted for multiple independent
variables is presented in Table 5. This multivariate model mutually adjusted for history
of sex exchange and participation in the street economy, current place of residence, religiosity,
number of family members aware of their sexual identity/orientation, and attendance at
gay bars/clubs. Many of the same relationships identified by the univariate analyses were
further supported in our multivariate approach; slight adjustments were made, however, to
estimates and confidence intervals to account for confounding effects. These analyses revealed
that respondents who had ever engaged in sex exchange were nearly four times more
likely to have recently used a club drug as compared to respondents who never participated
in sex exchange (OR = 3.95, CI = 2.23, 6.97). Similarly, those who reported having ever
participated in street economy were also nearly four times as likely to have recently used a
club drug as compared with respondents who had never participated in the street economy
(OR=3.71, CI=2.19, 6.28). Respondents who lived in their own apartment were also more
likely to report recent club drug use as compared with those living at home (OR = 1.78,
CI = 1.07, 2.96), as were respondents who frequent gay clubs and bars at least once a week
(OR = 1.97, CI = 1.10, 3.54), and respondents who reported that most or all of their family
members knew about their sexual identity/orientation (OR=1.99, CI=0.93, 4.25). In contrast
to the univariate regression results, the number of stressful life events was not found to
be an important risk factor after adjusting for multiple variables. There was no evidence of
lack of fit for this multivariate model (Hosmer-Lemeshow GOF chi2 = 14.50, p = 0.069).
Discussion
In this study,we found thatYMSMrecruited from gay-identified venues are a heterogeneous
population, with nearly all youth reporting use of alcohol and a sizable percentage reporting
lifetime and recent use of illicit drugs, particularly club drugs. While these findings provide
further evidence that YMSM are at high risk for illicit drug use, there are a number of
limitations of this study to be acknowledged. The findings rely on self-reported behaviors,
which cannot be independently verified. Self-report data regarding respondents’ use of
alcohol and drugs may have underestimated the true prevalence given that many of these
behaviors are illegal and socially undesirable, although we expect that the use of CAI
may have minimized the underreporting in these behaviors. The data are cross-sectional
and therefore do not contain information about the temporal relationship between some
of the demographic, psychosocial, and drug use variables explored in this study. Thus,
no statements can be made about the causal relationship between these variables. Finally,
although this sample is likely to be representative of YMSM who can be recruited through
gay-identified venues, this sample is not representative of the larger YMSM population.
Indeed, alcohol and drug use behaviors may be elevated within this segment of the YMSM
population given that they were primarily recruited from gay bars and clubs where they
might have increased access to illicit drugs.
Despite these limitations, this study provides clear evidence that the prevalence of
drug use (lifetime and recent) is high among YMSM who are recruited from gay-identified
venues, and that particular segments within this population are at especially high risk for
use of club drugs. Although we cannot make a causal link with the data reported here,
findings potentially suggest that attendance at gay clubs/bars and assimilation into the
gay community may be what first introduces YMSM to club drugs. The findings from
this research also suggest that a number of demographic and psychosocial variables may
put some YMSM at increased risk for club drug use. In this sample, young men were at
increased risk if they were older, Caucasian, frequented a gay bar/club more than once
a week, had previously been homeless, ever exchanged sex for something, and/or if they
were involved in the street economy. Young men were less likely to report recent club drug
use if they lived at home with their family and/or considered themselves to be somewhat
or very religious. Multivariate analyses that controlled for intercorrelation among these
variables further revealed that YMSM who frequently attend gay bars/clubs have a history
of homelessness, have ever exchanged sex, and who live in their own apartment or are
precariously housed are significantly more likely to report recent use of club drugs. In
contrast, YMSM who live with their family, considered themselves to be religious, and who
had disclosed their sexual identity/orientation to fewer family members were less likely to
report recent club drug use.
The findings from this research are significant for a number of reasons. First, they
provide very clear evidence that YMSM warrant special attention, separate from their
heterosexual peers and from older MSM. As reported in this article, our study sample of
YMSM was considerably more likely to report lifetime use of tobacco, alcohol, any illicit
drug, any illicit drug other than marijuana, cocaine, methamphetamine, and numerous other
drugs, as compared to a nationally representative sample of high school seniors. There
are numerous reasons why YMSM may be at greater risk than heterosexually identified
youth. MostYMSMwill experience some form of rejection, isolation, and/or discrimination
because of their same-sex sexual attractions/relationships. In their effort to define themselves
with respect to their sexuality, YMSM will often spend increasing amounts of time in gayidentified
venues such as bars, clubs, and other social settings, as they try to learn more about
the gay culture and what it means to be gay. This may bring increased risk and exposure to
illicit drugs. In addition, as YMSM sort through and reconcile their different selves—i.e.,
their role and place within their family, at school or in the workplace, with their friends, and
with respect to race, ethnicity, and culture—many will experience a range of conflicting
emotions, from excitement and enthusiasm to apprehension and fear. Drugs may be one
way to manage this fear and anxiety.
In our sample we found that a sizable percentage of respondents did perceive their
friends and parents to be supportive. As a result, family and peer support were not found
to be associated with recent club drug use. However, a sizable percentage of the sample
did report being depressed or distressed, experiencing a sizable number of recent stressful
life events, and having ever been homeless. In this case, all of these psychosocial
stressors—i.e., feeling distressed, increased number of stressful life events, and a history of
homelessness—were found to be significantly associated with recent club drug use. Being
“out” to most or all family and friends, frequent attendance at a gay bar/club, involvement
in sex exchange, and participation in the street economy were also found to be associated
with recent club drug use. Because late adolescence and early adulthood is a period of time
when behavioral patterns—both positive and negative—are established and reinforced, it is
particularly important that early interventions be targeted to build on protective influences,
bolster resiliency, and reduce YMSM’s risk for poor health outcomes.
The findings from this research help to fill some of the gaps in the literature that exist
regarding YMSM and their risk for drug use, but clearly more research is needed to further
characterize risk and protective factors∗ associated with drug use and associated health
problems, including HIV transmission. To be sure, more research is needed to further explore
the complex lives of these young people, and the range of individual, familial, social
and community influences that ultimately impact the health, well-being, and development
of YMSM. More research is also needed to clarify the different types of interventions that
might need to be developed to meet the specific needs of YMSM who are at high risk for
drug use and abuse—e.g., primary and secondary prevention interventions, linkage to treatment
services—as well as intervention intended to prevent negative health outcomes—e.g.,
HIV prevention interventions, linkage to HIV testing and treatment services, etc. Finally,
future research is needed to more fully characterize behavioral differences between different
segments of the YMSM population, particularly with respect to behavioral risk and health
profiles. Attempts to replicate these findings in other urban settingswould also be of interest.
Acknowledgements
This study was funded by the National Institute on Drug Abuse of the National Institutes
of Health (R01 DA015638–03). The authors wish to acknowledge the contributions of the
many staff members who contributed to this project: Cesar Arauz-Cuadra, Marianne Burns,
Julie Carpineto, Bryce McDavitt, Miles McNeeley, and Conor Schaye.
Notes
1. The term ofYMSMis used in this article although it is important to note that the YMSM,
as well as the adult MSM populations, are heterogeneous and not homogenous groups.
2. Recruitment extended throughout the course of the year in large part to account and
control for any potential seasonal variations that might have created sampling biases.

Sex, Drugs, Intervention, and Research: From the Individual to the Social

noreply@blogger.com (Landrogek) — Sat, 23 Feb 2008 19:09:00 +0000

Epidemiological estimates of the sexual risk behavior of drug users
have provided essential indicators to the current and future prevalence
of HIV transmission. An overview of recent research shows the majority
of drug injectors to be sexually active, low levels of reported
condom use, a significant minority of female injectors to be involved
in prostitution, relatively high levels of sexual mixing between drug
injectors and noninjectors, and only scant indications of sexual behavior
change. Epidemiological studies of risk, however, are unable to
yield the data required to understand the interaction between individual
risk behavior and social relationships. This is required if obstacles to
safer sex compliance and sexual behavior change are to be overcome,
and demands recognition of the influence and importance of social
context on the production of sexual risk behavior in future research
and intervention designs. In response, the paper explores the future
role of qualitative research in understanding the social relations of
“risk” and in contributing toward theoretical advancements in explanations
of risk perception and risk behavior. The paper concludes by
discussing the implications of this analysis for developing interventions
The advent of HIV infection and AIDS has encouraged public debate about
the most intimate of private behaviors. This debate has largely focused on the
sexual behavior and safer sex compliance of gay and bisexual men, women and
men involved in prostitution, and young people. In contrast, the primary focus
of research, intervention, and education targeting drug users has been injecting
behavior and-more specifically-the sharing of injecting equipment.
As mounting evidence indicates that drug injectors are changing their druginjecting
behavior in response to HIV and AIDS (Stimson, 1991), recent epidemiological
research has highlighted the importance of HIV-risk posed to
injecting drug users and their sexual partners through the sexual transmission
of HIV (Des Jarlais, 1992). In the United States, it is estimated that injecting
drug users are the source of HIV in at least three-quarters of heterosexually
transmitted cases of AIDS (Moss, 1987; Des Jarlais and Friedmaq1987). In
the United Kingdom, a drug-injecting partner is reported for over 60% of first
generation cases of heterosexual transmission (Evans et al., 1992). Concerns
predicting the “real heterosexual epidemic” to emanate from drug injectors
(Moss, 1987) have encouraged a “sexual re-awakening’’ for practitioners and
researchers working within the drug field. The recent British Governmenl
document and national health strategy Health of the Nation has fueled these
concerns by reaffirming the increasing significance of sexual transmission in
the future spread of HIV:
HIV is primarily sexually transmitted and prevention of infection depends
largely UPOR changes in sexual behaviour. (Department of
Health, 1992, p. 92)
This paper provides a brief overview of key research findings on the sexual
risk behavior of injecting drug users (IDUs) with the aim of discussing in
greater depth the role of future research and intervention in understanding and
responding to sexual risk behavior and sexual behavior change among drug
users and their sexual partners. It is argued first that there is a need for qualiiative
research to build upon current epidemiological understandings of sexual
risk so as to encompass understandings of the social relations and social context
of sexual behavior, and second that there is a concomitant need for interventions
to target social relationships (rather than simply individuals) so as to
overcome current obstacles to modifications in individual risk behavior and to
encourage wider social and community change.
DRUG TAKING AND SEXUAL RISK
Sexual Activity
Most studies of injecting drug use show the majority of IDUs to be sexually
active. One recent London study, for example, found 80% of drug injectors
to have had vaginal or anal sexual intercourse in the 6 months prior to interview,
and noted that two-thirds of IDUs had vaginal intercourse at least once
a week (Rhodes et al., 1994a). Despite the varying selection criteria and time
frames of measurement employed, other studies show similar proportions of
IDUs to be sexually active: 77% (Van den Hoek et al., 1990), 77% (Donoghoe
et al., 1989), 82% (Klee et al., 1990a), 86% (Coleman and Curtis, 1988).
Findings suggest that levels of reported penetrative sexual activity among
IDUs are comparable to those reported in the British adult population. One
recent study of heroin and cocaine users (IDU and non-IDU) found higher
levels of sexual activity than those in the adult population. In addition, the
average number of reported (noncommercial) sexual partners of IDUs in a 6-
month period (2.4 partners in London and 2.1 in Glasgow) have been found
to be slightly greater than comparative estimates in the British adult population
(Rhodes et al., 1993a).
Sexual behavior research among drug users prior to HIV infection and
AIDS focused primarily on the perceived pharmacological effects of drug use
on sexual activity. These studies suggested a reduction in sexual activity and
sexual interest to be associated with frequent opiate use (Mirin et al., 1980)
and an enhancement of sexual activity and interest to be associated with the use
of stimulants, such as amphetamines and cocaine (MacDonald et al., 1988).
Recent behavioral research undertaken in the context of HIV transmission has
supported an association between stimulant use and increased sexual activity
(Kall and O h , 1991; Fullilove et al., 1990; Chaisson et al., 1989). These
trends, however, are by no means consistent, and there remains considerable
uncertainty about their causal determinants (MacDonald et al., 1988; Washton,
1989; Marx et al., 1991).
Safer Sex Compliance
Most studies of injecting drug use show reported levels of condom use to
be comparable with those in the heterosexual population as a whole. They also
indicate greater likelihood and greater frequency of condom use with casual
partners than with primary partners. Recent findings in London, for example,
show that in a 6-month period two-thirds (68%) of drug injectors never used
condoms with primary partners and over a third (34%) never used condoms
with casual partners (Rhodes et al., 1994a). Other reports indicate that 79%
of injectors in Glasgow (Rhodes et al., 1993a) and 75% of injectors in the
West Midlands (Klee et al., 1990a) never use condoms. Safer sex compliance
with primary partners has been shown to be statistically associated with an
awareness of HIV positive antibody status (Van den Hoek et al., 1992). although
studies also indicate relatively high levels of continued sexual risk
behavior among HIV-positive IDUs (Rhodes et al., 1993b). Surveys of anonymously
tested saliva samples in London also show that the majority of HIVpositive
IDUs are unaware of their positive status (Donoghoe et al., 1993;
Rhodes et a]., 1993b).
A combination of commonsense assumption and research evidence suggests
that drug use has a disinhibitory effect on decision-making about sexual safety
and on safer sex compliance (see Rhodes and Stimson, 1994). While there
remains little comparative or conclusive research in this area, recent research
has associated higher levels of sexual risk behavior with increased severity of
drug dependence (Gossop et al., 1993), frequent amphetamine use, temazepam
and polydrug use (Klee et al., 1990b), and cocaine or crack use (Chaisson et
al., 1991).
Most United Kingdom studies conclude that condom use remains at insufficient
levels to prevent the potential for further sexual transmission of HIV
between drug injectors and their sexual partners, particularly given average
rates of partner change and the significant minority of injectors who also continue
to share used equipment with people other than their sexual partners
(Rhodes et al., 1993a).
Prostitution
There is an established overlap between an involvement in injecting drug
use and an involvement in female prostitution, Estimates in London show 14%
of women prostitutes attending sexually transmitted disease (STD) clinics (Day
et al., 1988) and 33% contacted through street outreach (Rhodes et al., 1991)
to inject drugs. Estimates elsewhere range from 25% (Kinnell, 1989) to 59%
(McKeganey and Barnard, 1992). Studies of injecting drug use also indicate
a high proportion of female injectors to be involved in prostitution: recent
estimates suggest 14% in London and 22% in Glasgow (Rhodes et al., 1993a:i.
There is little evidence of injecting drug use among male prostitutes (Bloor et
al., 1992).
As is the case with female sex workers (Day et al., 1988), female IDUs
involved in sex work report higher levels of condom use with paying partners
than with nonpaying partners. In Glasgow, female IDUs involved in prostitution
report almost 100% condom use with paying partners compared with 9%
“always” condom use with nonpaying primary partners and 22 % “always”
with nonpaying casual partners. In London, female IDUs involved in prostitution
report 70% “always” condom use with paying partners (Rhodes et al.,
1994b).
Estimates of HIV prevalence among women prostitutes have found higher
rates of prevalence among prostitutes with a history of injecting drug use, and
in European and North American countries evidence associates HIV transmission
among prostitutes with an involvement in injecting drug use rather than
with an involvement with prostitution per se (Padian, 1988; Van den Hoek et
al., 1988; McKeganey et al., 1992). In the absence of controlled studies designed
to assess the relative risks of sharing used injecting equipment and
sexual transmission of HIV, it is difficult to determine the epidemiology of
epidemic spread among drug-using and nondrug-using prostitutes. A recent
prevalence survey in London found HIV infection to be no higher among female
IDUs involved in prostitution than among IDUs not involved in prostitution
(13% compared with 14%) (Rhodes et al., 199413). This adds further
support to emerging evidence which suggests that prostitution per se is not
independently associated with HIV prevalence or HIV risk behavior.
Sexual Partners
Studies show a relatively high degree of sexual mixing between injecting
and noninjecting drug users: approximately half of the sexual partners of injectors
are estimated to be noninjectors while approximately half of injectors
report noninjecting sexual partners (Rhodes et a]., 1993a). The vast majority
of these partners are women. This is in part an artifact of injecting drug use
being a predominantly male activity and in part because male injectors show
specific preferences for noninjecting female partners (McKeganey and Barnard,
1992). Such preferences may also be more likely with primary (i.e., more
important longer term) partners than with casual partners (Rhodes et al.,
1994a). This poses increased sexual risks to the noninjecting sexual partners
of injectors, and in particular to female primary partners, for whom contact
with an injecting drug user may be their only significant risk factor. It is within
primary relationships that condom use is most infrequent, while a significant
minority (between 16% and 19%, Rhodes et al., 1993a) of injectors report both
primary and casual partners in a 6-month period.
There are few studies which have explicitly involved the sexual partners
of drug users in research. North American qualitative research indicates the
difficulties female sexual partners of injectors have in initiating and negotiating
strategies of protection not only for themselves but also for their partners
both with regard to safer sex and needle safety (Wermuth et al., 1992; Kane,
1991).
There are few longitudinal or cohort studies of sexual behavior change
among drug injectors, and in comparison to studies of injecting and sharing
practices, only scant indications of change. Although some studies point tci
reductions in the number of sexual partners and sexual encounters and increased
levels of reported condom use (Skidmore et al., 1989), these have been
limited changes, and some studies report either no change or increased levels,
of sexual risk behavior over time (Des Jarlais et al., 1992; Calsyn et al.,
1992). The lack of notable sexual behavior changes relative to changes in drugtaking
behavior among drug users probably relates to a combination of factors.
These include injectors’ own assessments of sexual risk as relative to drugrelated
risks (Jain et al., 1991), the problems experienced in translating knowledge
about sexual risk into action, the primary focus of research, intervention
and education agencies on modifications in injecting behavior, and the associated
notions of identity and responsibility which this has created and reinforced
within drug-injecting communities about sharing and drug-using practices
(Rhodes and Quirk, 1996).
RESEARCH: EXPLAINING THE INDIVIDUAL AND SOCIAL
DYNAMICS OF “RISK’
Current Epidemiological Explanation: Some Possible
Improvements
Conventional epidemiology is concerned with the study of the distribution
and determinants of disease (Barker and Rose, 1984). In the case of the public
health response to the HIV epidemic, epidemiological research has provided
essential indicators of the distribution and determinants of HIV disease among
injecting drug users. This has provided baseline quantitative indicators on levels
of sexual activity and sexual risk behavior among drug users and their sexual
partners and has laid the foundation for the development of a range of HIV
prevention and safer sex health promotion initiatives targeting changes in individual
sexual lifestyles.
As HIV transmission routes among injecting drug users shift from parenteral
to sexual routes as safer injection becomes more commonly adopted
(Schoenbaum et al., 1989), it is important that future epidemiological studies
of sexual risk behavior both clarify and improve indicators of the distribution
and determinants of sexual activity and sexual risk behavior. Current epidemiological
explanations of sexual risk among drug injectors can be improved
in four main ways.
First, there remains a need for greater comparability between studies in
measures of sexual risk behavior. At minimum, indicators need to include
measures of the frequency, type, and number of sexual partners; frequency and
type of penetrative and nonpenetrative sexual encounters; and frequency of
condom use and safer sex. Most previous studies have employed partial indicators
of sexual risk, usually as a component of investigations primarily concerned
with drug-taking practices. Reliable epidemiological indicators of HIV
risk need to measure the interaction between the frequency and type of drugrelated
and sex-related risk behavior. It is fundamental also that studies remain
comparable in the time-frames of measurement (i.e., period of recall) and
categories of measurement (i .e., continuous or dichotomous) employed
(Samuels et al., 1992), as well as in the definition of key “risk” variables (e.g.,
“prostitution,” “safer sex”).
One possible methodological development in the measurement of drugtaking
and sexual risk behavior is the use of retrospective and prospective selfcompletion
diaries. Sexual diaries have provided an effective and reliable means
of data collection among gay and bisexual men, minimizing problems of recall
and providing a detailed and time-coded description of sexual encounters
(Coxon, 1988). The feasibility and reliability of using diaries as a method of
data collection among drug users is largely unknown. The use of diary methods
may provide more accurate assessments of the interaction between drug
taking and sexual risk, allowing examination of the causal dynamics of the
relationship between drug use and sexual activity by gathering time-coded
behavioral data within specific drug use and sexual encounters. Such analyses
may also provide opportunities for delineating the dynamics of the pharmacological
relationship between drug use and sexual risk and the influence of interpersonal,
situational, and social context on the perceived and experienced
effects of drug use on sexual behavior.
Second, improvements can be made to sampling designs. The majority of
studies of HIV prevalence and HIV risk behavior among drug users draw on
highly selective samples drawn primarily from drug user treatment and agencybased
populations (Samuels et al., 1992). The majority of drug users, however,
remain out of contact with treatment and helping services (Frischer, 1992), and
a number of studies have indicated higher levels of HIV prevalence and higher
levels of drug-related HIV risk behavior among nontreatment populations
(Lampinen et al., 1991; Donoghoe et al., 1993). Less is known about the
degree to which “hidden” populations of drug users also engage in sexual
transmission behaviors, and the influence (if any) of drug treatment on health
behavior changes not directly related to drug use such as sexual health is unclear.
The desire to change HIV transmission behavior, however, may be an
equally important determinant of changes in drug taking and sexual behavior
than the influence of drug treatment and helping services per se, while those
engaging in higher levels of risk related to drug use may also have a propensity
for higher levels of risk behavior as a whole. Future epidemiological research
needs to simultaneously recruit samples from a variety of drug user
treatment and nontreatment settings, with the aim of investigating the possibility
of bias in indicators of risk which rely primarily on clinic and agency-based
samples (Alcabes et al., 1992).
Third, improvements can be made to study design. The majority of studies
employ cross-sectional study designs with retrospective measures of risk, and
there are few longitudinal or cohort studies of sexual risk behavior and sexual
behavior change among drug users. While there are practical and methodological
difficulties inherent in cohort study designs among drug users (Vlahov and
Polk, 1988; Samuels et al., 1992), if future studies are to yield data on the
problems and possibilities of sexual behavior change, ideally these should simultaneously
include longitudinal as well as cross-sectional designs.
Fourth, improvement can be made to current epidemiological measurements
of “risk behavior.” Current studies invariably take the individual as the
unit of analysis. Because HIV infection is a behavioral disease, its progression
is not random or uniform but subject to much variation and change. Reliable
epidemiological indicators of the distribution of HIV risk and HIV spread require
a measure not just of the frequency and type of risk behavior in individuals
but also a measure of the interaction and epidemiological efficiency of
mixing patterns between individuals (Vlahov et al., 1990; Samuels et al.,
1992).
In addition to the individual, it is equally important that future epidemiological
study takes as its unit of analysis “social units” of drug injectors, defined
in terms of the social and epidemiological ties and connections between
individuals which are relevant for investigating HIV transmission. These social
units range from particular relationships between individuals as in the case
of friendship or sexual dyads to wider social relationships of individuals as with
drug dealing and friendship networks. Since it is the interaction between individuals
which determines HIV transmission, shifting the unit of analysis toward
“social units” to determine the epidemiological efficiency of these inter -
actions enables greater reliability in assessments of risk and in estimates of
cpidemic spread.
One priority for future research in this area includes an assessment of the
assortative and disassortative* sexual mixing patterns among drug injectors and
the sexual partners of drug injectors. While current research has highlighted
an increased risk of HIV infection to the noninjecting sexual partners of injec-
tors, there are difficulties in estimating the associated risks of sexual transmission
to noninjecting heterosexual populations without concomitant knowledge
of the sexual mixing patterns of both injectors and their sexual partners.
Theorizing Risk: The Limits of Individualism
Conventional epidemiology remains locked into a conception of risk which
is restricted to the individual (Tannahill, 1992). As noted above, most epidemiological
study takes the individual as its unit of analysis and most explanation
and prediction is based entirely on measures of individual risk behavior
(see Table 1). Such explanations are limited because they remain blind to a
variety of other social and cultural processes which influence the ways in which
individuals behave, and thus also the ways in which epidemics spread. As
recently suggested, the social impact and significance of HIV-risk can only be
understood and explained by “filling-in and questioning the empty categories
of epidemiological prediction” (Kane, 1991, p. 1037).
It is in this context that it is important to note that epidemiology and epidemiological
approaches have largely framed the focus and parameters of lay
and professional understanding about HIV infection and AIDS (Herdt and
Lindenbaum, 1992). As noted by Berridge, epidemiologists have played the
lead part in defining and ordering the disease and in giving it a name
(Berridge, 1992). It is important to recognize that it is epidemiological understandings
and categories of “risk behavior” and of “risk groups” that have
informed and defined the boundaries of psychosocial behavioral research investigating
the determinants of individual risk behavior and lifestyle.
Psychosocial models of research and health behavior based upon individualistic
lifestyle notions of risk are often inadequate to address the complex
social realities of risk acceptability, risk perception, risk assessment, and behavior
change (see Table 1). These models, which emphasize the “health beliefs”
(Becker, 1974), “self-efficacy’’ (Bandura, 1977), and motivations and
skills (Joseph et al., 1988) of individuals to behave in certain ways, recognize
a cognitive decision-making process in risk perception and risk behavior but
fail to adequately capture either their social dimensions or their complexity.
While providing pointers to behavioral intention, this is often devoid of social
and cultural explanation or understanding (Romer and Hornik, 1992; Ingham
et al., 1992). Such research has been found to have a limited capacity and
utility in either predicting or explaining health beliefs about sexual risk and
sexual behavior change (Rosenstock et al., 1988; Bloor et al., 1992; Montgomery
et al., 1989).
Current epidemiological and psychosocial theorizing on risk perception and
behavior is based on the assumption of individual rationality (Rhodes, 1995).
Dominant theoretical approaches to understanding health behavior-such as
derivatives of the theories of Reasoned Action, Planned Behavior, and the
Health Belief Model (see; Ingham et al., 1992; Becker, 1974; Fishbein and
Azjen, 1975; Azjen, 1988)-view “risk-taking” as the result of an individual’s
rational decision-making based on the perceived costs and benefits of risk action.
At their crudest, such models of explanation assume a single rationality
of choice-making about risk (Rhodes, 1995). Choices to avoid risk, which are
frequently spoken of in health promotion discourses as the “healthy choices, ”
are seen as “reasoned” choices, as exemplars of rational rather than irrational
behavior. This often demeans explanations of continued risk behavior among
IDUs to the rather dubious scientific categories of “unreasoned” behavior and
cognitive malfunction.
Recent attempts to move beyond “single rationality” theories of risk perception
toward theories of “situated rationality” overcome some of these limitations
but clearly remain inadequate (Bloor, 1995; Rhodes, 1995). These theories
recognise that rationality is inextricably linked to the specific situations and
contexts in which choices about risk are made. They go as far as to allow a
plurality of rationalities and thus move beyond a one-dimensional matrix of
“cost and benefit” where cost is synonymous with risky actions and benefit is
synonymous with their avoidance. “Situated rationality” theories of risk behavior
may help explain, for example, why condom use by IDUs with casual
partners has increased over time while condom use with primary partners has
remained relatively constant. Our current qualitative work on sexual negotiation
indicates that in some cases HIV-negative IDUs may continue to have
unprotected penetrative sex with their HIV-positive partners, despite knowledge
and understanding of the proximity and susceptability of risk (Rhodes and
Quirk, 1996). “Situated rationality” theories would posit that these decisions
about risk are reasoned by individuals on the basis of costs and benefits which
are situation and context dependent (e.g., where loss of trust or intimacy may
be perceived to be of greater cost than the risk of HIV).
But as we noted above, “situated rationality” theories remain inadequate
to explain the social realities of risk behavior. As with other derivatives of
theories of “reasoned action,” they assume that decisions about risk action are
calculated. While in some instances this may be the case, this does not recognize
the habituation of risk behavior (Bloor, 1995). Many of the behaviors
in which IDUs routinely engage, whether deemed “risky” by themselves or by
social scientists, are everyday behaviors which occur in a mundane or unspectacular
fashion, often without individual “decisions,” “choices,” or “calculations”
having to be made. Because such theories are ostensibly theories of
individual cognition, they are unable to recognize that individual rationalities
and perceptions are socially organized:
If a group of individuals ignore some manifest risks, it must be because
their social network encourages them to do so. Their social
interaction presumably does a large part of the perceptual coding on
risks. (Douglas, 1986, p. 67)
The individualism of current theories of risk provide limited understandings
of risk behavior. “Risk” is neither perceived nor understood by individuals
as a neutral category but is socially and culturally organized and acted upon
(Douglas, 1986, 1992; Douglas and Wildavsky, 1983; Bloor, 1995, Rhodes,
1995; Hart and Boulton, 1995). This means that epidemiological understandings
and measures of risk-particularly when applied in survey-based research-
often lack social and cultural specificity and appropriateness. They fail
to account for the ways in which risk is socially and culturally defined and the
ways in which individual understandings of risk are socially and culturally
mediated (see Table 1). Because individual rationalities are based on wider
socially organized boundaries of explanation and meaning, “risks” are not simply
or only “calculated” by individuals and neither is risk action necessarily
individually “chosen” or “decided” upon. It is for this reason that the notion
of risk taking is both inaccurate and misleading. The “choices” which current
psychosocial research paradigms assume to be “taken” by individuals are COMcomitantly
determined by a combination of social, cultural, and economic factors.
What social scientists often view and measure as being individual volktion
may sometimes not be “choice” at all (e.g., cases of sexual persuasion,
“negotiation,” and coercion, or unsafe sex for money). Contemporary explanations
of HIV and sexual risk behavior provide little notion or measure of
“the social.” Parrallels can be made with anthropological critiques of how
theorizing on risk has tended toward the “deculturing” of individuals:
Expert risk analysis takes as its decision-making unit the individual
agent, excluding from the choice any moral or political feedback that
he may be receiving from his surrounding society. The rational agent
of theory is decultured. (Douglas, 1986, p. 67)
Rather than focusing exclusively on the psychological determinants of individuals
in risk-related encounters, there is a need for future research to recognize
how individual perceptions of risk and individual capabilities to control
risk-related encounters are relative, both to wider peer-group, social, and community
norms and to situational and structural context (see Table 1). The fundamental
aim of such research is to focus on the pattern of interaction between
risk behavior and social relationships and less on individual decision-making
and the risk behavior patterns themselves (McKeganey and Barnard, 1992).
Investigating the relationship between individual risk perception and social
context encourages an understanding of the obstacles to individual behavior
change. This demands a shift in direction toward a more qualitative action
oriented research paradigm suited to investigating the social contexts and social
relations of drug use and sexual activity (Rhodes and Stimson, 1994).
This new paradigm of HIV risk research aims to build upon current epidemiological
and sociological understanding of sexual risk behavior among
drug users in an attempt to provide pragmatic support to developments in health
promotion and intervention. It is our contention that it is timely and important
that a new paradigm of sexual risk research requires more than evidence of risk
behavior and of behavior change: it also needs to investigate and influence the
process of change.
Understanding the Social Processes of Risk
We have suggested that epidemiological research is of incontestable importance
in mapping the future determinants of epidemic spread, and that this
contribution is best invested in an understanding the interactive nature of risk
and risk behavior. While epidemiological and psychosocial study is suited to
mapping the determinants and distribution of individual risk perception and
behavior cross-sectionally and longitudinally, it currently lacks the descriptive
capabilities to understand the social processes which determine the ways in
which perceptions and behaviors are produced. It is unable to appreciate the
subjective nature of the objects of study.
What is needed is a move toward an interactive paradigm of research
which is inclusive of sociological and anthropological methodology and explanation.
At the outset this demands a shift from conventional epidemiological
approaches toward a “social epidemiology” which aims to classify the determinants
of disease and illness on the basis of their social and economic origins
(Paterson, 1981; Scott-Samuel, 1989; Tannahill, 1992). The role of sociological
and anthropological research in this context is twofold.
First, it aims to describe the personal and social meanings attached by
individuals and by groups of individuals to specific behaviors categorized as
“risky” by the epidemiologist. This means describing behavior in the context
of the meanings participants themselves have ascribed to their behavior. Behaviors
attributed “risky” by the epidemiologist are thus to the qualitative sociologist
part of a wider structure or culture of behaviors and associated meanings,
which to participants themselves are often viewed and experienced as “normal,”
rational, even mundane (Schwartz and Jacobs, 1979). This means understanding
risk behavior in the context of drug users’ everyday lives:
For the IV drug using subculture in particular, the risks associated
with AIDS transmission overlap with a constellation of risks about
which we know little. The concept of risk-taking as a common and
meaningful dimension of the lives of IV drug users has so far been
hidden behind an externally-constructed pastiche of risk behaviours
specific only to AIDS. (Connors, 1992, p. 591)
Second, it aims to understand the processes by which individuals come to
attach meaning to “risk behaviors” and the ways in which individuals interact
with wider systems or structures of knowledge and influence about HIV, risk,
and health. This means investigating the social and cultural production of
knowledge about HIV-related risk (of which epidemiology and dominant scientific
discourse is a part) in the light of other situational and environmental
factors which influence health behavior. Overall, the aim is to understand the
“reciprocal effects of social settings upon individuals and of individuals upon
social settings” (Schwartz and Jacobs, 1979, p. 9) with the objective of determining
the problems and possibilities of reducing drug and sex-related harm.
The move toward such a research paradigm demands fundamental shifts
in contemporary thinking about social problems. As noted above, conventional
epidemiology has played the key role in identifying and defining HIV risk and
in influencing how policy and health interventions should best respond. The
need to view HIV infection and HIV risk as socially constructed problems requires
untangling the processes which have been key to “inventing” HIV and
AIDS (Patton, 1990). One of the challenges of the second decade of AIDS is
to bring about fundamental shifts in how research aims to reconstruct the social
realities of health behavior and everyday life among populations affected
by HIV transmission. As has been observed in the field of risk perception:
A very significant body of work views risk perception as an individual
and not as a social phenomenon. . . . It seems that the neglect of culture
is so systematic and so entrenched that nothing less than a large
upheaval in the social sciences would bring about a change. (Douglas,
1986, p. 1)
Understanding Drug Taking and Sexual Risk
A closer inspection of current research explanations of the relationship
between drug taking and sexual risk demonstrates the importance of viewing
sexual risk behavior as a socially organized interaction. Here we use the example
of crack and cocaine use (see Rhodes and Stimson, 1994, for a full
discussion).
There is mounting epidemiological evidence which shows there to be an
association between the use of crack and cocaine and increased levels of reported
sexual activity and sexual risk behavior (Wolfe et al., 1990; Fullilove
et al., 1990; Chitwood and Comerford, 1990; Chaisson et al., 1989, 1991).
This reflects contemporary concerns that stimulant drugs (and in particular,
cocaine and crack) have disinhibiting effects on safer sex compliance:
The danger of crack lies in its potential to promote high-risk sexual
behavior through which AIDS can be contracted [italics added].
(Bowser, 1989, p. 539)
More than a cursory glance of the epidemiological literature reveals that
there are many studies which show no such associations or which show such
associations to be complicated by an interaction of social, situational, and
material factors (Hartgers et al., 1991; Wolfe et al., 1990, 1992; Inciardi,
1989). While studies show associations between cocaine and crack use and HIV
positivity, there are few studies of sexual transmission and few which show
these to be causal associations in people without a history of injecting drug use
(Marx et al., 1991; Chaisson et al., 1991).
While the current epidemiological picture remains blurred (see Marx et al.,
1991, for a review), it is becoming increasingly clear that sexual risk behavior
among crack and cocaine users is determined by a range of social, situational,
and cultural factors which often remain peripheral to the vision of
epidemiology. Two examples help to demonstrate this.
First, ethnographic research has shown the importance of social and group
norms in influencing individuals’ perceptions, expectations, and accounts of the
effects of crack on sexual behavior and performance (Inciardi, 1989; Carlson
and Siegal, 1991). This means that there is often a subcultural “mythology”
attached to crack and sexuality which informs individual and group expectations
and understandings of the effects of crack and cocaine on sex-related
behavior. While sexual behavior in crack-related encounters may vary depending
on an interaction of social, situational, and material factors (see below),
individuals often make sense of such experiences in a limited number of ways
in the light of shared knowledge about what is legitimate (i.e., “normal”)
behavior. It is important to study both the processes by which knowledge is
socially organized and the ways in which individuals interact with this body
of knowledge to make sense of their own behavior:
We may make more sense of people’s explanations, especially when
given in social contexts, if we . . . acknowledge that, as accounts,
common-sense explanations often serve to excuse and justify, and not
merely to explain. (Hewstone, 1989, p. 37)
Second, ethnographic research has shown that in some crack-related settings
it is normal and legitimate for the drug to be exchanged for (often unsafe)
“sexual favors” which are often initiated and performed by men as “degradation
rituals” (Carlson and Siegal, 1991). These encounters are often not
viewed or understood as “prostitution” by the participants concerned but are
seen as a necessary or usual component of the drug deal and of the crack-related
encounter. While this may be documented as being of epidemiological importance
given the increased sexual risks associated with crack use, this cannot
fully explain the processes which determine such events. Such sexual
encounters are determined not simply by an interaction between pharmacology
and individual psychology but by a complex interaction between the individual
and the social which determines both the economics and currency of drug and
sex exchanges.
Future research which aims to investigate and influence sexual behavior
change among drug users requires an understanding of the social, cultural, and
material exchange “value” of behavior and the ways in which such values and
meanings limit the predictive and explanatory effectiveness of rational and
decision-making models of individual behavior.
INTERVENTION: FROM INDIVIDUAL TO SOCIAL CHANGE
HIV Prevention and the Limits of Individual Change
While ethnographic research points to indications of large-scale and community
changes in drug-injecting behavior (Burt and Stimson, 1993), HIV
prevention programs targeting drug users have found greater difficulty in promoting
and achieving sexual behavior change (Table 2). In recognizing the
inadequacy of interventions based on biomedical notions of individual lifestyle
and sexual behavior change (Ehrhardt, 1992), the challenge for safer sex health
promotion is to both create and nurture a collective and social responsibility
about sexual behavior and sexual health.
The recent advocation and adoption of community-based HIV prevention
strategies targeting harder-to-reach drug users may provide the foundation and
stimulus for such a response (Rhodes, 1993, 1994a, 1994b). Current UK interventions
are predominantly focused toward the individual client and toward
achieving individual behavior change. These initiatives attempt to contact drug
users, the majority of whom are out of contact with existing health services,
with the aim of enabling them with the means to make safe choices about drugtaking
and sexual behavior.
The effectiveness and efficiency of current UK models of community-based
HIV prevention have recently come under critical review. Recent evaluation
has raised important questions about the limitations of community-based interventions
which work within a mode of health education dominated by an individualistic
focus. Evaluation of the UK syringe exchange schemes, for example,
has indicated the inherent limitations of the approach in encouraging and
sustaining behavior change among drug injectors in the community and in
social environments where risk behavior is actually produced (Stimson et al.,
1991; Stimson and Donoghoe, 1996). Despite the availability of injecting
equipment though syringe exchanges, “choices” about whether to share such
equipment are also influenced by particular social relationship dynamics (e.g.,
between sexual partners), social desirability, and social acceptability. Qualitative
research in Glasgow, for example, notes differences in patterns of sharing
among women and men where sharing was found to be a “socially embedded
behaviour which [was] responsive to the many rights and obligations” within
social relationships (Barnard, 1993).
While outreach and extra-agency work enables education in situ-within
the social environments where risk behaviors are produced-this also largely
remains targeted toward individuals with the aim of encouraging “self-empowerment”
on a client-centred basis (see Table 2). Evaluation of street-based
outreach questions the utility of such an approach, pointing to wider social and
material factors (e.g., peer group norms, housing and welfare needs) which can
impede the effective promotion and adoption of changes in individual lifestyle
and sexual risk behavior (Rhodes and Holland, 1992).
This confirms ethnographic and behavioral research which shows the importance
of social and peer group norms and of situational and social setting
in shaping behavior change (Rhodes and Hartnoll, 1996). If intervention is to
build effectively on the findings of recent research, greater emphasis must be
placed on the targeting of networks and communities as objects and as agents
of change rather than individuals and individual risk behavior alone (Friedman
et al., 1992, 1994; Rhodes, 1993, 1994b; Stimson et al., 1994). This is necessary
as a first step to creating the social relations in which individuals can
exercise “choices” about their health behavior.
Toward Social Network and Community Change
There are few UK interventions which explicitly attempt to encourage
collective or community change among drug users, and there remains considerable
inexperience in using the appropriate intervention methods to achieve
these aims. UK interventions have much to learn from their international counterparts
(largely US and Australian) reportedly effective in encouraging community
change (Wiebel, 1988; Friedman et al., 1992; Friedman et al., 1994;
Trotter et al., 1993) and much to learn from studies of community participation
and organization in health promotion as a whole (Rogers and Shoemaker,
1971; Rogers, 1983; Bracht, 1990; Tones et al., 1990; Freire, 1972).
In understanding the possibilities for initiating and reinforcing change in
social networks or communities of drug users, it is useful to draw on the established
theories and practices of community development and, in particular,
communication and diffusion of innovations (Rogers and Shoemaker, 197 1 ;
Rogers, 1983). Communication of innovations theory provides important guiding
principles which govern the conditions necessary for change and the likelihood
of change being adopted. There are essentially four principles (Tones
et al., 1990): the characteristics of communities govern the need and desire for
change; the ownership of, and identification with, an innovation (or intervention)
by a community governs the likelihood of adopting and sustaining change;
the process of change is governed by the homophily* existing between community
leaders and change agents; and the process of change is governed by
the characteristics and perceived consequences of change.
To move beyond the limitations of interventions targeting individuals as
agents of change, interventions first require knowledge of the characteristics
and structure of drug-using social networks. This is necessary so as to understand
and monitor the possibilities for diffusion, of the “processes by which an
innovation is communicated through certain channels over time among the
members of a social system” (Rogers, 1983, p. 5). Analysis of social network
structure thus requires epidemiological and sociological mapping of the nature
and structure of social relationships within social networks. As noted by Scott
on the subject and method of social network analysis:
Relations are not the properties of agents, but of systems of agents;
these relations connect pairs of agents into larger relational systems.
(Scott, 1991, p. 3)
This means describing the “contacts, ties, and connections” between individuals
within a network with the aim of delineating the channels of communication
and influence for targeted innovations. It is for this reason that the
role of outreach worker or peer educator often overlaps with the role of community
ethnographer and that many outreach programs in the United States
have developed simultaneously in the light of ongoing ethnographic intervention-
based research (Wiebel, 1988, 1996; Feldman and Aldrich, 1990; Grund
et al., 1996). An ethnographic description of drug-using special networks thus
consists of “a body of qualitative measures of network structure” (Scott, 1991,
p. 3) delineating the “specific type of relation linking a defined set of persons”
(Knoke and Kuklinski, 1982, p. 12).
More particularly, it is important to gauge the extent to which specific
networks or communities of drug users are homogeneous. The extent as well
as the specific nature of connections within networks clearly influences the
feasibility for diffusion of communications. Each individual drug user can be
seen to have a multitude of ties into a number of overlapping ego-centered
networks: it is the job of ethnography to determine which particular ties into
which particular networks are relevant for targeting as potential channels of
diffusion into group-centred networks. The potential that drug-dealing networks
hold for communication of innovations, for example, may differ from the
potential that drug-using, friendship, or sexual networks have. The heterogeneity
within as well as across social networks and communities of drug users
across time and space must be considered the first obstacle to targeting social
networks as a way of instrumenting “community change” (Rhodes, 1993). In
contrast to a greater developed sense of collective social and political identity
among communities of gay men, for example, identities, “ties and connections”
within social networks of drug users may be more functional than ideological,
and perhaps more imagined than real (Rhodes, 1994a). Interventions encouraging
community change within drug-using networks thus need to build upon
existing social ties, norms, and values by first identifying perceived needs for
change and second by creating and nurturing a sense of collective identity and
shared responsibility about innovation and change in individual and collective
health behavior.
Available evidence points to the effectiveness of interventions targeting
peer influence as a method of facilitating collective action and community
change. Among gay men, research has demonstrated the importance of collective
action in first creating the social and cultural conditions necessary for
sexual behavior change and second in influencing and reinforcing the validity
and efficacy of continued changes in sexual behavior (Ehrhardt, 1992; Hart and
Boulton, 1995). A number of studies show greater sexual risk reduction
changes among gay men who are socially integrated into existing gay social
networks than among gay men who are not (Kippax et al., 1992; Freeman et
al., 1992). Studies also show that greater sexual risk reduction changes are
reported among gay men who receive social and peer support when attempting
changes in their sexual behavior and condom use (Kelly et al., 1990,
1992). Crucially, controlled comparative evaluation shows greater sexual risk
reduction to be achieved among those targeted by peer group organizing within
preexisting social networks than by conventional individually-targeted health
education alone (Kelly et al., 1992).
While drug-using subcultures are often characterized by social relationships
which appear unconducive to the creation and reinforcement of collective social
responsibilities (Friedman et al., 1990), recent research has demonstrated
both the normative importance of sharing in drug users’ social and material
relationships (McKeganey and Barnard, 1992) and of peer support in influencing
behavioral norms and behavior change (Friedman et al., 1992). Friedman
et al. (1992), for example, note the importance of peer support from the drugusing
and nondrug-using friends and relatives in changing drug users’ sexual
behavior (Abdul-Quader et al., 1989) and condom use (Sotheran et al., 1989),
while condom use among female sexual partners of drug users (Tross et al.,
1992) and among women enrolled in methadone treatment programs (Ramos
et al., 1992) have also been found to be associated with peer support and
endorsement.
It is well established that longer-term more experienced drug users often
initiate and “educate” new recruits into appropriate drug-taking behavior (Des
Jarlais et al., 1989). Future interventions might begin by targeting such individuals
within specified social networks with the aim of encouraging them to
impart health recommendations to new recruits into drug use and to individuals
new to their social networks and social circles.
Examples of Social Network and Community Change
Since 1987, the US National Institute of Drug Abuse (NIDA) has funded
a number of demonstration outreach projects targeting drug injectors and their
sexual partners. Of key importance has been the development of “Peer Driven”
and “Indigenous Leader Models” of outreach (Wiebel, 1988, 1996; Broadhead
and Heckathorn, 1994; Koester, 1992) and recent moves toward social network
interventions (Trotter et al., 1993). One of the best established demonstration
projects targeting community changes among injecting drug users is the Chicago
AIDS Community Outreach Intervention Project (Wiebel, 1988, 1996).
Developed initially as a method to intervene and control community outbreaks
of heroin use, it combines epidemiological indicators of risk behavior with
community-based ethnography as a way of designing and implementing appropriate
intervention in the community. The project employs a sequence of strategies
to identify and execute appropriate intervention targets with the overall
aim of facilitating collective change (Wiebel, 1988).
First, the use of qualitative and ethnographic methods and of ethnographers
are outreach workers helps identify community norms and values attached to
health behaviors. Second, the use of former and current drug users as outreach
workers and ethnographers facilitates access to target populations and communication
with target drug users. Third, the repeating of outreach contacts using
a series of complementary risk reduction messages at different locations
maximizes health recommendation exposure and reinforces its content. Fourth,
and most significantly, the targeting of key individuals and their subsequent recruitment
as AIDS Prevention Advocates to enhance and impart health recommendations
to their friends and peers helps encourage socially responsible
beliefs and opinions about health behavior, and, over time, generates a collective
response to behavior change.
The Chicago outreach project can be seen to embody many of the classic
heath promotion strategies developed in communications of innovations theory
(Rogers and Shoemaker, 1971; Rogers, 1983). It is based on sound epidemiological
and ethnographic assessment of the structure and shared norms of identified
social networks, and it employs ideas of homophily in the use of indigenous
outreach workers/ethnographers and key community leaders as peer
educators. This gives indication of the likelihood of change being adopted and
of the possibilities for reinforcing and sustaining the process of change overtime.
The project has been effective in encouraging risk reduction changes over
time and recently has been associated with a declining incidence of new HIV
infections among target populations (Wiebel et al., 1994).
The Chicago project can be seen as a model intervention where ethnographic
observation informs intervention strategy and response (Wiebel, 1996).
One other model intervention, recently developed in Connecticut, provides an
example of a social network intervention where the preexisting structure of
social networks is defined less by a priori ethnographic research than by IDUs
and their peers themselves (Broadhead and Heckathorn, 1994; Grund et al,
1996). The East Connecticut Outreach Project (ECHO) employs ethnography
to make initial contact with IDUs and to develop and implement appropriate
intervention messages, but thereafter encourages IDUs, by a coupon system of
peer-referral, to contact and educate their peers (see Grund et al., 1996, for
a description of intervention methods). All IDUs receiving education from their
peers are encouraged to do likewise and educate peer contacts of their own and
to make contact with the core outreach team for assessments of peer education
given and received. Whereas the Chicago project builds up a picture of the
structure and connections within drug-using social networks by ongoing ethnographic
observations, the ECHO project begins to identify the structure of
preexisting networks by the connections which are made between peers involved
in the outreach intervention.
This means that no a priori assumptions are made as to what a network
is or of how it best operates with regard to the communication of health interventions.
While the Chicago project operates within the paradigm of “Indigenous
Leader Models” of intervention aiming to identify which IDUs within
a network have “leadership” status or potential, the ECHO project operates
within a paradigm of “Peer Driven Models” of intervention which aim to identify
and exploit preexisting channels of communication and influence as they
“naturally occur” within social networks (Broadhead and Heckathorn, 1994;
Grund et al., 1996). The Chicago project aims to diffuse communication within
networks by identifying which individuals appear to have most influence in
maintaining or “policing” network norms, while the ECHO project aims to
diffuse communication by a cue-system based on preexisting power and organi
zational structures (peer to peer rather than “peer educator” to peer). Without
altering the dynamics and nature of communication flow within networks, the
ECHO project aims to encourage a system of “group mediated social control”
where groups or networks of people “police” themselves (see Heckathorn,
1990, for a theoretical outline of Group-Mediated Social Control, and Broadhead
and Heckathorn, 1994, for a description of its application to HIV outreach).
While the ECHO project remains in its developmental stages (6 months
implementation at the time of writing), preliminary findings from process evaluation
suggest that it is well received by IDUs (Grund et al., 1996).
Social network interventions may also be planned and developed on the
basis of systematic social network analysis. Work undertaken by Trotter and
colleagues points to the pragmatic value of an intimate and synergistic linkage
between social network analysis and intervention (Trotter et al., 1993). Such
research has shown how ethnographic research undertaken among key target
populations may lead to a realization that there exists a luck of cohesion within
and across bounded groups of drug users. Exploration of the interplay between
such groups produced a closer understanding of the extent and nature of connections
within different “types” of drug-using networks, which ranged from
“closed networks” displaying an absence of social interaction between members
to “open networks” where membership was based on acquaintance and
acquiescence (Trotter et al., 1993). Social network interventions require an understanding
not simply of whether connections between drug-using individuals
and groups exist but of the nature and suitability of these connections for
the feasibility and diffusion of interventions.
At the time of writing there are few published evaluations of “peer education”
or social network interventions encouraging group-mediated change
among drug users. Ethnographic field research has shown the value of understanding
preexisting channels of communication and influence within drug-using
social networks when targeting key individuals as peer educators or health
advocates. As well as drug dealers and drug users, key individuals selected as
peer educators have included local shopkeepers, bar workers, and managers of
shooting galleries (Oeullet et al., 1991; Murphy and Waldorf, 1991). The
comparative value of peer or “indigenous leader” interventions against those
which tend to be “peer-driven” remains unknown. It is clear, however, that
future HIV prevention interventions need to make fundamental shifts toward
encouraging group rather than individually-mediated change within social networks
of drug users (Rhodes and Hartnoll, 1996).
While little is known about the scope, feasibility, and effectiveness of peer
interventions among drug users, preliminary research findings suggest that
interventions targeting the changing of community norms may do more to
change risk behavior than interventions targeting changes restricted to individuals.
Friedman et al. (1992) reported on the preliminary findings from a community
organizing initiative emphasizing collective identity and participation
among drug injectors in Brooklyn, which they show achieved greater levels of
risk reduction in sexual and drug-taking behavior than street-based individually-
focused outreach (see also Jose et al., 1996).
Evaluation of syringe exchange in Rotterdam shows a higher return rate
of equipment, a higher retention rate of attendance, and higher levels of risk
reduction from an intervention recommending collective change and encouraging
drug users to take care of their friends and peers than from a similar intervention
recommending individual change (Grund et al., 1992). Similar findings
are reported from peer-based syringe exchange projects in South Australia,
which shows that peer-based programs were more effective in distributing
equipment and in reaching new injectors than nonpeer-based programs (Herkt.
1993).
Peer education and peer endorsement may be particularly important in the
context of behaviors most private and subject to most social and public policing,
such as sexual behavior (Ehrhardt, 1992). The targeting of peer influence
as a method of initiating and reinforcing change in drug users’ social and
sexual relationships can be viewed as a first step toward encouraging a process
of community and collective change. It also may be considered the first
step toward providing the foundation for community mobilization and organization
among drug users in defining and controlling collective norms and values
about health behavior and in confronting the social constraints which marginalize
equity to public health.
CONCLUSION
An understanding of the obstacles to individual behavior change requires
an understanding of the social context of risk behavior. Without confronting
the obstacles to behavior change it is unlikely that opportunities for change will
be created. This demands an approach to research and intervention which recognizes
both an epidemiology and a sociology of risk behavior. It is timely for
a shift in the direction and emphasis of most research and intervention designs
toward a conception of risk behavior and behavior change which encompasses
and combines a vision of the social as well as the individual. If intervention
is to be effective in changing individual risk behavior, then it must also be
effective in changing the social context of risk behavior. It is timely for research
and intervention to consider the problem of the social and of social
change. This is one of the challenges of the second decade of AIDS. When
facing this challenge, drug users themselves may prove to be the most helpful
advocates of innovation and change.

Self Ratings of Dependency/Addiction Regarding Drugs, Sex, Love, and Food: Male and Female College Students

noreply@blogger.com (Landrogek) — Sat, 23 Feb 2008 19:03:00 +0000

To what degree do addictions to drugs, sex, love, and food correlate
with each other? Are there meaningful sex differences in
the addictions? To study this, 9,313 college students (3,083 males,
6,230 females) rated 13 items on 0–100 scales for their dependency/
addiction to the things represented by the items. Results
indicated that males reported significantly more addictions than
females, but females were more likely than males to report addictions
for cigarettes, chocolate, and food in general. Results also
showed consistent intercorrelations, typically in the 0.20’s or 0.30’s,
but sometimes higher. Not only did things correlate within their
category—e.g., the different drugs correlated with each other, indicating
polydrug use—but correlations occurred between unrelated
topics, such as dependency/addiction to alcohol correlating
with dependency/addiction to having sex. The findings support the
notion of small but significant overlap in the various dependencies/
addictions, and of sex differences in the various addictions.

Is addiction pervasive, or does it operate in just one area? For example, if a
person is addicted to cigarettes, would they also be addicted to marijuana?
What about chocolate? Or, heroin? It is also important to know if the two sexes
differ in how they respond to the extent of their dependency or addiction to
various substances, including drugs, food, sex, and love.
People try to control their lives and their environment, and the extent
to which they can control things has a lot to do with their well-being, as
opposed to having addictions that control them (Deci & Ryan, 2000; Ryan,
Kuhl, & Deci, 1997). Addiction would seem to be at one end of a continuum,
with self regulation at the other end (Deci & Ryan, 2000; Maddux, 1995;
Ryan, Kuhl, & Deci, 1997; Vielva & Iraurgi, 2001). Using the term “addiction”
in a general sense would also encompass a person feeling dependent on
something. That is the person’s feeling of dependency or addiction to something
indicates their feeling of lack of control. There is some evidence that a
person who lacks control in one area often has additional problems in other
areas (Oltmanns, Neale, & Davison, 2003). And, one bad experience can
lead to subsequent problems in other areas of life (Riggs, Dancu, Gershuny,
Greenberg, & Foa, 1992).
The control that people feel over their lives is an important part of
who they are. Most addictions detract from feelings of control. If people
feel compelled by outside forces, or by inner demons, then they do not
see themselves as being able to exert self control. One concept which has
enjoyed an increased popularity in recent times is “addiction.” Originally used
with regard to drugs, the concept of addiction has been added to such things
as sex and food. Thus, we can conceptualize someone as being a sex addict
or a food addict, which implies that they behave compulsively in these areas,
and have little control over their behavior.
Related to feeling that one is a victim is a related concept of being
dependent on drugs, sex, love, food, etc. Dependency, too, implies that
the individual does not have total control or freedom but must depend on
something else to feel complete, to feel adequate. The inability to regulate
oneself or to control events in one’s life can be a major problem (Eisenberg
& Zhou, 2000; Eisenman, 2000, 2001, 2003a, 2003b; Epstein & Katz, 1992;
Rotter, 1990; Singh & Darroch, 2000; Zuckerman, 1991).
Some of the concepts mentioned here can be broken down into smaller
units, or divided into different forms. For example, there are different types
of drugs, and a person may be addicted to/dependent on one without having
the same problem(s) with other drugs. Or, a person may be addicted to
sex but not love or vice versa. While the concept of sexual addiction has
been explored (Carnes, 1983, 1989, 1990, 1991), the idea of being addicted
to love has received less attention. Sometimes, people have strong emotional
feelings and a lack of control. The idea of sexual addiction is controversial.
We may not need the concept to understand compulsive sexual behavior,
and it may not be desirable to add such a diagnostic term which implies that
sex addiction is like drug addiction (Eisenman, 2001). But, self-described
addiction or dependence would seem to indicate a real problem. For example,
if a people say, they have chronic illnesses, their life would not seem
to be very enjoyable. The mere perception of a constant illness would help
make things unpleasant. Likewise, believing that one has a dependence or
addiction would seem to contribute negatively to one’s happiness or feelings
of comfort. We wish to know if the drug addictions/dependencies are related
to one another, suggesting problems with polydrug use, and if drug addiction/
dependency is related to addiction/dependency in other areas, such as
love, sex, food, etc.
METHOD
Participants
The participants were 9,313 college students (3,083 males, 6,230 females)
in the United States and Canada. They were a convenience sample, tested
by cooperating professors in these two countries, who asked students from
their classes to answer a longer questionnaire, in order to find out about
sex differences in drug and other addictions, and to find out about the intercorrelation
of addictions. The data are drawn from these questionnaires,
which also contained other questions besides the ones discussed here. The
addiction questions were analyzed for sex differences in the addictions, and
for intercorrelations among the addictions.
Self-Ratings
The subjects were asked to provide ratings with regard to the following
question: “To what degree have you ever felt yourself becoming dependent
upon, or addicted to, the following things?” The students were told to
employ a 0–100 scale, with “0=not at all” and “100=to the most extreme
degree.” The students were given 14 categories for the 0–100 ratings: alcohol,
amphetamines, barbiturates, being in love, chocolate, cocaine, coffee,
cigarettes, gambling, having sex, heroin, marijuana, and food in general.
RESULTS
The results are shown in Tables 1–5. Table 1 shows the mean scores for the
addictions by gender: males vs. females. Table 2 reports t tests for the different
addictions by gender. Table 3 presents the correlations for all subjects,
while Table 4 presents the results for males only, and Table 5 presents the
results for females only. It is apparent that being dependent or addicted to
one thing is frequently—but not always—associated with being dependent
or addicted to something else.
There were many sex differences, with males usually more likely to have
reported dependency/addiction to the various topics. Males reported significantly
more addiction for the areas of alcohol, amphetamines, barbiturates,
cocaine, gambling, having sex, heroin, and marijuana. Females reported significantly
more addiction for chocolate, cigarettes, and food in general. Being
in love and coffee both had small, nonsignificant differences, with females
slightly higher in both. For the entire sample (males and females) the addiction
ratings, on a 0–100 scale, ranged from a low of 0.40 for females for
heroin (males 0.74) to a high of being in love, at 49.67 for females (males
49.13).
For the entire sample, i.e., both sexes combined, most of the items show
a statistically significant correlation with one another, although sometimes
quite low. At times, though, the correlations have a moderate but not low
relationship, as when being dependent/addicted to barbiturates correlates
0.52 with dependence/addiction to amphetamines. The low intercorrelations
may be due, in part, to the low amount of addictions admitted to by the
participants in this study. Such limited admission of addictions would usually
result in small or nonsignificant findings.
For dependency/addiction in males only, amphetamines correlated 0.56
with barbiturates, 0.49 with cocaine, and 0.41 with marijuana. Being dependent/
addicted to being in love correlated 0.48 with those dependent/addicted
to having sex. The results for males only are summarized in Table 4.
For dependency/addiction in females only, amphetamines correlated
0.49 with barbiturates, 0.48 cocaine, and 0.38 with marijuana. Being dependent/
addicted to being in love correlated 0.49 with those dependent/addicted
to having sex. The results for females only are summarized in Table 5. For
the variables discussed in this and the preceding paragraph, the male and
female correlations are very similar. Both sexes show a multidrug usage pattern
with being dependent/addicted to one drug having moderate relationships
to being dependent/addicted to other drugs regardless of what drug
one examines: cocaine, alcohol, cigarettes, amphetamines, etc. For example,
dependency on/addiction to marijuana shows statistically significant correlations,
indicating dependency on/addiction to other drugs. And both sexes
show a moderate relationship between sex and love dependency/addiction.
It is not as though females link sex and love and males do not or vice versa.
Both sexes show about the same correlation between love and sex.
As with the males and females combined, the separate male and female
correlations usually show some statistically significant correlation between
one kind of dependency/addiction and another. In part, this is due to the
large sample size that can make very low correlations statistically significant.
But, if one looks at the actual correlations, many are in the 0.20’s or 0.30’s,
suggesting that some degree of variance in one variable is related to some
degree of variance in the other.
DISCUSSION
The results suggest that the concept of being dependent or addicted is a
meaningful one to college students, in that there was some admission of
dependency or addiction to a variety of areas, including both drug and nondrug
areas. And if they admit to a dependency or addiction in one area, there
is often a dependency or addiction in another area. At times, this seems to
make sense, as with the correlation between some of the drugs (users often
have a multidrug use pattern) or between sex and love. We would expect
that sex and love dependency/addiction might go together, to some extent.
However, at other times the results are by no means obvious such as when
the combined male and female sample dependency/addiction on chocolate
correlates 0.24 with dependency/addiction to being in love (0.19 for males
and 0.28 for females). Both food and sex are natural drives, but it is not
obvious that there would be any kind of relationship between the two. The
results of the present study suggest that there is somewhat of a food and sex
relationship, at least for those admitting dependency or addiction in these
areas.
The results are consistent with past studies or theories indicating that
there is often an interrelationship between a person’s addiction in one area,
e.g., drugs and/or sex, and their addictive problems in a different area, e.g.
eating disorders (Crowther, Wolf, & Sherwood, 1992; Fairburn, Hay, & Welch,
1993; Gordon, 1990; Hoek, 1995; Shisslak, Crago, & Estes, 1995). The results
are also consistent with previous studies that have shown usually small but
significant relationships among addictive behaviors or among addictive behaviors
and other problem behaviors (Dembo, Getreu, Williams, Berry, La
Voie, Genung, Schmeidler, Wish & Kern, 1990; Gorman & Derzon, 2002;
Jessor, Chase, & Donovan, 1980; Sieber & Angst, 1990).
The results also show important sex differences, with men usually more
likely to admit to addictions than women. All the drug items have men higher
than women. Men were also significantly higher than women in ratings of
being addicted to gambling and to sex. Women were only higher in addiction
to cigarettes, chocolate, and food in general. The last two are food items.
Thus, males reported greater addiction to drugs than females and females
reported greater addiction to two food items, chocolate and food in general.
Females also reported greater cigarette addiction than males. Only the items
of being in love and coffee showed no significant gender differences. The
results are what one might expect, given biological differences between the
sexes and gender roles, with males being more adventuresome than females
in the areas of sex and drugs. Perhaps love appeals equally to both sexes,
and thus there was no difference.
The results also suggest the utility of the dependency/addiction concept.
Although many are skeptical of referring to people as sex addicts or food
addicts, there may be some value in such a concept. However, the results
further suggest caution, in that the addictions seem to fit together to only a
modest degree. That they do fit together shows the value of the dependency
or addiction concept. That they do not fit together more strongly means we
should not always conclude that a person with a dependency or addiction
in one area will necessarily be dependent or addicted in another area. But
we must consider the possibility of a correlation, since the self-report data
show that there is often some overlap.
Self-report data are always susceptible to distortion. It may be that the
data reflect a response set with people willing to admit to one kind of dependency/
addiction often admitting to another kind. Future research could
investigate if there are addictions to, for example, chocolate, and if there
really is an overlap with addiction to being in love. Do people just think
they are this way, or do addictions to various areas really exist? This could
have important clinical implications for those working with addicted people.
The sharp clinician, based on the present data, would look for dependency
problems in different areas.
Bandura’s concept of self-efficacy often can explain why people do or
do not do something (Bandura, 1977). Perhaps a major problem for the participants
in this study is that they often lack self-efficacy feelings regarding
the various substances (drugs, food) or concepts (love, sex). People with
self-efficacy feel that they have control over what they are doing (Bandura,
1977). In contrast, a person who feels dependent or addicted to something
does not have that control. Thus, the lack of control may be somewhat
general, as revealed by the intercorrelations in the present study between
areas that do not necessarily seem related. A person who lacks self efficacy
with regard to, for instance, alcohol, will have problems with that drug
(Sitharthan, Job, Kavanagh, Sitharthan, & Hough, 2003). It would be interesting
to find out if learning self efficacy—or other improvements in one’s life—
in one specific area, led to generalized improvements in other areas as well.
From the present data, we can speculate that such may well indeed be the
case.
Many people try to quit undesirable behavior on their own, without undergoing
any professional intervention (Curry, Ludman, & McClure, 2003).
Thus, it is often difficult to know how well a person has succeeded in overcoming
a problem. The fact that the problems may intercorrelate to some
degree—as suggested by the current findings—means the person has tough
road ahead. On the other hand, the present data also imply that if the person
succeeds in correcting one area, corrections in other, unrelated areas may
also occur.
The results are consistent with the view that there may be some
usefulness in the concept of sexual addiction (Blanchard & Tabachnick,
2002; Carnes, 1983, 1989, 1990, 1991; Corley & Schneider, 2002), at
least defined within narrow boundaries (Eisenman, 1994) or utilizing
self report. Sexual dependency/addiction here was linked with other dependencies/
addictions. And, there were meaningful sex differences. It
appears that addiction has an overall, pervasive nature, such that addiction
in one area has moderate correlations with addictions in other
areas.

Knowledge, attitude and practice of modern contraception among single women in a rural and urban community in Southeast Nigeria

noreply@blogger.com (Landrogek) — Sat, 23 Feb 2008 19:00:00 +0000

Summary
The contraceptive information and services offered to single women in most developing countries is compromised by
stigma attached to premarital sex. This study was to ascertain the knowledge, attitude and practice of contraception among
single women in a rural and urban community in southeast Nigeria, using a cross-sectional survey of 279 and 295 single
women in Ngwo (rural) and Enugu (urban) community. The mean age of the population was 21.3 years. Contraceptive
awareness was more among the urban than rural respondents (90.2% vs 34.1%). The major sources of contraceptive
knowledge were mass media (68%) and peer groups (86.3%) for the urban and rural respondents, respectively. Most
respondents in both groups had positive attitude towards contraception. More urban than rural respondents (68.3% vs
12.5%) began sexual activity during adolescence and the level of contraceptive use during first coitus were 48.4% and
13.7%, respectively. Of the currently sexually active respondents, 32.5% (rural) and 59.7% (urban) were using a form of
modern contraception. Condoms, followed by oral pills were the most popular contraceptive method because they can
easily procure them over the counter. Poor contraceptive information, highly critical behavior of family planning providers
towards unmarried women seeking contraception and attitude of male partners militate against contraceptive practice.
There is need to promote information and education on contraception among single women, their male partners and
family planning providers.
Introduction
The society today is more permissive to sex, with the
effect that more and more single women are engaging in
pre-marital relationship and sex. This results in a high
incidence of unwanted pregnancies and abortion among
these sexually active single Nigerians due to limited
access to family planning services (Feyisetan and Pebley
1989). These single women face special circumstances,
which make it difficult for them to obtain the reproductive
health they need even when it is seemingly available.
Such problems include the psychology of being seen
among married women in the family planning clinics. By
lowering the probability of unwanted pregnancy, contraceptives
can decrease the need for abortion, but as in
most African countries contraceptive use in Nigeria is
low (Fakeye and Babaniyi 1989; Nigeria Demographic
and Health survey 1991). Government and donor
agencies are committed to an active family planning
policy and have taken measures to make available a
broad range of contraceptive methods as well as
informing the general public of its availability (Mamadani
et al. 1993).
In this article, we report on in-depth interview exploring
knowledge, attitude and practice of various forms of
modern contraception among single women living in urban
and rural areas of southeast Nigeria.
Materials and methods
The study was conducted in Enugu metropolis and a rural
Ngwo community both in Enugu state in southeast
Nigeria. Enugu is the capital of Enugu state of Nigeria
and is located east of the river Niger. It has a projected
population of one million persons and is divided into nine
zones based on respective residential areas. The major
occupations range from trading to civil service. The
metropolis has a teaching hospital (University of Nigeria
Teaching Hospital), a general hospital (Park Lane Hospital),
12 government health centers, 142 private hospitals
and clinics and 800-registered patent medicine dealers and
pharmaceutical stores. Ngwo on the other hand, is a rural
community in Udi local government area of Enugu state
and is situated to the west of Enugu town. It has an
estimated population of 160,000 and is made up of 10
villages. Ngwo has 20 health facilities: 4 government health
centers and 16 private clinics and maternity homes. Ngwo
by proximity shares cultural norms with Enugu town and
they are predominantly farmers with few civil servants. The
inhabitants of both communities are predominantly Ibos
with pockets of other tribes.
Multistage sampling technique and cross sectional
sample survey were done between January and April
2004. Uwani, one of the nine districts in Enugu metropolis
was selected by simple random sampling from a list of all
the districts after which 11 streets were purposely selected
from it. Two hundred and ninety-five unmarried females
aged between 15 and 49 years (reproductive age group)
were selected by systematic random sampling technique. In
Ngwo, two (Uboji and Ameke) out of the 10 villages were
selected by simple random sampling and 279 unmarried
females of reproductive ages selected by systematic random
sampling technique.
Using pre-tested interviewer-administered questionnaires
information were sought on age, educational
status, religion, income of respondents or their guardians,
knowledge, attitude and practice of modern contraception.
Female nurses who were trained in interviewing technique
conducted the interviews. The entire 574 questionnaires
were completed and analysed, giving a response rate of 100
percent. The data analysis was done by simple percentages
and mean using Graph pad software.
Results
Of the 574 respondents, 279 (48.6%) were living in the
rural area while 295 (51.4%) reside in the urban area. Their
age ranges from 15 to 49 years with a mean age of 21.3
years (Table I). The rural and urban respondents were
mainly Christians of Roman catholic (53.4% vs 63%) and
Anglican (41.9% vs 33.9%) denominations, respectively.
They were of mixed socioeconomic status with almost 50%
of those in the rural area and 21.6% of the urban
respondents earning less than one hundred dollars
monthly. More than 50% of the respondents in both urban
and rural communities had attained menarche by 14 years.
While most respondent attained secondary education,
there were more respondents with tertiary education
among the urban than rural single women (36.9% vs
11.8%). Twelve percent (n = 35) of urban and 5.4%
(n = 15) of rural respondents gave a history of previous
pregnancy.
Table II shows that more respondents in the urban area
(57.6%) had good knowledge of their period than the
respondents in the rural area (37.3%). Also 90.2% of the
urban respondents knew about contraceptives as against
34.1% of the rural respondents. Mass media and information
from peer group were major sources of knowledge of
contraception for urban and rural respondents, respectively.
57.3% of the rural respondents and 63.1% of urban
respondents have been exposed to sexual intercourse and
more of the urban than rural respondents (68.3% vs
12.5%) had this experience as adolescent. While 48.4% of
the urban respondents practised contraception during their
first coitus, only 13.7% of rural respondents did the same.
Sixty percent and 32.5% of the sexually active urban and
rural respondents, respectively are currently using one form
of contraception or the other. Condoms, followed by oral
pills were the most popular contraceptive method in the
two groups of respondents. Seventy-six percent of the rural
and 71.4% of the urban respondents who knew about
contraception favored its use by single women. They were
also willing to recommend the use of contraception to their
friends. Majority of the male sexual partners of the urban
respondents had a more positive attitude towards their use
of contraception than those of rural respondents (64.5% vs
40.6%). For male partners of rural respondents contraception
will encourage promiscuity while condom
diminishes sexual pleasure. The partners of urban respondents
on the other hand, view condom as a way of
minimising risk of sexually transmitted diseases as well as
avoiding pregnancy.
Of the respondents using contraceptives, the greatest
obstacle to its use is the embarrassment of going to procure
it especially from the family planning clinic (Table III).
Discussion
In this study, a higher percentage of urban respondents
knew about the fertile period and contraception than those
in the rural area. This level of contraceptive knowledge
among these urban respondents agrees with studies in
other urban sub-Saharan Africans (Bisrat and Pickering
1994). Despite campaign on information dissemination in
family planning in developing countries (Piotrow et al.
1990; Valente et al. 1994), the level of contraceptive
awareness we have documented among rural single women
indicate that changes are rather slow. Most of the rural
single women lacked basic information about reproduction
and contraception and often did not know where or how to
obtain contraceptive information. Furthermore, there were
social, psychological and economic barriers to accessing
these services. The mass media was an important source of
information for most urban women in this study and this
was in agreement with previous studies in Nigeria (Konje et
al. 1998; Adinma and Nwosu 1995). However, the same
cannot be said for the rural women who depended more on
friends and peer group for contraceptive information, some
of which is false. This lack of adequate information and
ignorance has been shown to be key factors militating
against family planning practice in Nigeria (Adinma and
Nwosu 1995). There is therefore a need to bridge the gap
in contraceptive information by redirecting information
dissemination, counselling strategies and restructuring
family planning programmes to facilitate grass root coverage.
Most of the respondents in both rural and urban areas
were sexually experienced with 12.5% of rural and 68.3
percent of urban respondents beginning sexual activity
during adolescence. The first sexual encounter of these
adolescents, as in previous studies (Izugbara 2001) was
promoted by pressure, curiosity and for economic purposes.
These adolescent women face unique problems in
practicing birth control and in doing so effectively. They do
not have accurate or adequate information about effective
contraceptive method and far too often those who have the
knowledge cannot obtain the services and supplies they
need because they may be confronted with social ostracism
for their acknowledgement of sexual activity outside
marriage. It was therefore not surprising that 13.7% of
rural respondents and 48.4 percent of urban respondents
used some form of contraception at first coitus. Greater
availability and access to contraception together with
relaxation of norms governing pre-marital sexual relationships
in the urban areas may account for the differences in
contraceptive usage of the two groups at first coitus.
The level of contraceptive use among currently sexually
active respondents in the urban area is higher than those in
the rural area. This urban-rural difference in contraceptive
practice may be a function of contraceptive awareness,
educational level, previous pregnancy experiences and life
style (Fantahun et al. 1995; Versnel et al. 2002; Spinelli et
al. 2000; Hartlage et al. 2001). It is instructive to note that
all the urban respondents with previous history of
unwanted pregnancy were currently using a method of
contraception. However, this was not the case for those in
the rural area because of non-availability of contraception
or lack of information about its existence. Furthermore, the
highly critical behavior of family planning providers
towards unmarried women who sought contraception tend
to compromise the quality of services offered to these
women (Anate et al. 1997). Since abortion is still restrictive
in Nigeria (Solanke 1977), these unmarried women tend to
resort to clandestine abortion practices after an unwanted
pregnancy.
Condom was the most popular method of contraception
employed by both respondents, followed by oral contraceptive
pills. The reasons for this is obvious, as they can
easily procure them over the counter without the embarrassment
associated with going to the family planning
clinic. Also, most of the single women only have occasional
sex and felt emergency contraceptive pills situated their
situation.
Majority of both rural and urban respondents that knew
about contraception had favorable attitude toward it and
were willing to recommend it to others. However, the
support of the male partners of the rural respondents for
the use of contraception was poor. Ignorance, fear of
promiscuity and diminished sexual pleasure with condoms
were part of the reasons given. On the other hand, majority
(64.5%) of the male partners of the urban respondents
were supportive on the need for family planning and were
willing to promote the use of condom. They believed that
using condom is the best way to minimise the risk of
sexually transmitted diseases as well as preventing pregnancy.
In addition to place of residence, the socioeconomic
and educational status of the male partner of the single
women influenced their attitude towards contraception.
In conclusion, it has become obvious that there is an
urgent need to promote information, education and
communication programmes on contraceptives among
our rural dwellers. Also more effort should be made to
integrate men into the various aspects of reproductive
health programmes. And finally the communication barrier
between the family planning provider and single women
seeking contraceptive advice should be bridged.

Effect of Sex, Menstrual Cycle Phase,and Oral Contraceptive Use on Circadian Temperature Rhythms

noreply@blogger.com (Landrogek) — Sat, 23 Feb 2008 18:18:00 +0000

Summary: The circadian rhythm of rectal temperature was continuously recorded over
several consecutive days in young men and women on regular nocturnal sleep schedules.
There were 50 men, 21 women with natural menstrual cycles [i.e., not taking oral contraceptives
(OCs) (10 in the follicular phase and I 1 in the luteal phase)], and 14 women
using OCs (6 in the pseudofollicular phase and 8 in the pseudoluteal phase). Circadian
phase and amplitude were estimated using a curve-fitting procedure, and temperature
levels were determined from the raw data. A two-way analysis of variance (ANOVA) on
the data from the four groups of women, with factors menstrual cycle phase (follicular,
luteal) and OC use (yes, no), showed that temperature during sleep was lower during the
follicular phase than during the luteal phase. Since waking temperatures were similar in
the two phases, the circadian amplitude was also larger during the follicular phase. The
lower follicular phase sleep temperature also resulted in a lower 24-h temperature during
the follicular phase. The two-way ANOVA showed that temperature during sleep and
24-h temperature were lower in naturally cycling women than in women taking OCs. A
one-way ANOVA on the temperature rhythm parameters from the five groups of subjects
showed that the temperature rhythms of the men and of the naturally cycling women
in the follicular phase were not significantly different. Both of these groups had lower
temperatures during sleep, lower 24-h temperatures, and larger circadian amplitudes than
the other groups. There were no significant differences in circadian phase among the
five groups studied. In conclusion, menstrual cycle phase, OC use, and sex affect the
amplitude and level, but not the phase, of the overt circadian temperature rhythm. Key
Words: Circadian rhythms-Core body temperature-Menstrual cycle-Birth control
pills-Oral contraceptives.

There have been very few comparisons of circadian body temperature rhythms between
young men and women. Winget et al. (1) reported that men had larger circadian amplitudes
and lower mean levels than women, but they did not find a sex difference in circadian
phase. Wever (2) measured the temperature rhythms of free-running, internally
synchronized subjects and also found larger amplitudes and lower mean levels in men.
Rogacz et al. ( 3 ) studied women across the menstrual cycle and noted that they had
smaller amplitudes than men previously studied in their laboratory, regardless of menstrual
phase.
Hormonal changes across the female menstrual cycle affect the circadian temperature
rhythm, with progesterone having a thermogenic effect (4). The menstrual cycle
can be roughly divided into two phases: follicular (the time froin menses onset to ovulation)
and luteal (the time from ovulation to menses). Progesterone levels are low during
the follicular phase and high during most of the luteal phase, peaking in the middle
of the luteal phase. Estrogen levels are low at the beginning of the follicular phase, rise
during the last few days of the follicular phase, and are reduced but remain high during
the luteal phase (5,6). Women taking the commonly prescribed oral contraceptives
(OCs) receive an estrogen plus a progesterone for 2 I days of the 28-day cycle and no
active ingredients during the other 7 days (7).
There have been several studies of the circadian temperature rhythm in women with
natural menstrual cycles, i.e., in those not taking OCs. The amplitude of the rhythm IS
larger during the follicular phase than during the luteal phase, primarily due to a lower
nocturnal temperature, which also results in a lower daily mean temperature level
(3,8-13). Longitudinal graphs of temperature from single subjects across the entire
menstrual cycle show the interaction between the circadian and infradian (menstrual)
cycles (8,14). Most studies find no change in circadian phase across the menstrual cycle
(1 0,l I , 15,16), but a few preliminary studies suggest a phase delay during the luteal
phase (9,13). There is a paucity of data regarding the effects of OC on the circadian
temperature rhythm.
Given the differences in the temperature rhythm across the menstrual cycle, those
who make comparisons between women and men need to take female menstrual cycle
phase into account. The purpose of this report is to compare the circadian temperature
rhythms of men and women, taking menstrual cycle phase and OC use into account.
METHODS
The data were taken from the baselines of various studies performed in our laboratory
(1 7-20). During baseline, which was either 7 or 10 days long, participants adhered
to a regular sleep schedule, with fixed bed times and wake times and exactly 8 h in bed.
Subjects were required to remain in bed, in the dark, for the entire 8 h, even if they could
not sleep. The time of the sleep period was similar to the subjects' habitual sleep schedule,
except that the sleep times were closer to the weekend sleep times to avoid masking
the minimum of the temperature rhythm by early wake times. The experimental
schedule was also fixed and regular, in contrast to the irregular schedules of most young
adults. To ensure compliance to the sleep schedule, subjects were required to call a timestamp
answering machine just before bed time, immediately after waking, and 30 min
after waking. They were also required to keep daily sleep logs of estimated sleep onset
and wake times. In general, the reported sleep times were similar to the scheduled sleep
times. Caffeine consumption was restricted to either no caffeine at all or else only in
the first 4 h after wake time and in the exact same amount every day. Alcohol and recreational
drugs were prohibited.
Before the studies began, female subjects were asked if they were using OC and when
their last menstrual period began. During the studies they checked a box on one of the
daily logs to indicate whether or not their period started on that day. For women not
using OC, conservative estimates of the two primary menstrual phases were made by
counting forward or backward from the day of menses onset. The average length of the
luteal phase is - 14 days and is rarely < 12 days (21). Therefore, we classified the 12
days prior to the onset of menses (reverse cycle days - 1 to - 12) as luteal days. The
average length of the follicular phase is - 13 days and is rarely < 10 days (22). Therefore,
we classified the day of menses onset and the following 9 days (forward cycle days
0 to +9) as follicular days. Since we used only data from the 22 days of the menstrual
cycle centered around the day of menses onset and did not include days close to the follicular
to luteal transition, we avoided classification errors. Given this method, if one
or both phases of a particular cycle were longer than usual, this would not cause a misclassification.
However, a misclassification could conceivably occur if the particular
Meal or follicular phase included was extremely short and happened to end during
baseline.
For women using OC, we defined the “pseudoluteal” phase as the 2 I days during
which exogenous estrogen plus progesterone are taken, to correspond to the natural
luteal phase with its increased levels of estrogen and progesterone. We defined the “pseudofollicular”
phase as the 7 days without exogenous hormones, to correspond roughly
to the natural follicular phase with low progesterone. For women taking OC, menstruation
occurs during the week with no exogenous hormones (7), beginning on about the
second day. Therefore, we made conservative estimates of pseudoluteal and pseudofollicular
days counting from the day of menses onset. Pseudofollicular days included
days - 1 to +2, and pseudoluteal days included all days except days -5 to +5.
For each subject, only the data from one phase of the cycle (luteal or follicular) were
used: the phase with more baseline data. In cases where participants had exactly equal
numbers of baseline days in their luteal and follicular phases, they were randomly
assigned to one of the groups and the data from the other phase were discarded.
Core body temperature was continuously measured using a rectal temperature probe
and either a Vitalog PMS-8 or Consumer Sensory Products AMS-1000 portable monitor
programmed to store measurements every minute. The probes were inserted and maintained
at a constant distance (1 0 cm). Subjects were told to take the probe out for exercise,
baths, showers, and sex so that extremely elevated temperatures were not recorded.
The temperature data of each subject were averaged into 15-min points and divided
into 24-h sections. The sections started at 2 1 :00 so that each section contained a complete
nocturnal sleep episode. If the data during sleep were missing or if half or more
data for any 24-h section were missing, the entire 24-h section was not used. We included
only subjects for which we had at least three 24-h sections.
The 24-h sections for each subject were averaged, and then two measures of temperature
level were calculated. The average temperature during sleep was calculated for
each subject using the scheduled bed time and wake time for each subject. Thus, this
measure was actually the average temperature during in-bed time. The 24-h temperature,
or mean temperature during the whole 24-h period, was also calculated.
A curve consisting of the fundamental cosine curve plus three additional harmonics
(the 12-, 8-, and 6-h harmonics) was fitted to the average curve of each subject. The
time of the minimum was used as a phase marker. The minimum was chosen, rather
than the maximum, because the minimum occurs during sleep, a time of relative inactivity,
and is thus less affected by masking from activity. Fitting a curve with three harmonics
smoothed the data and provided a single minimum. This method is similar to
visually picking the minimum, but more objective. More harmonics could have been
added to the fitted curve, but as more are added, the fitted curve approaches the actual
data curve and is not as smooth. Circadian amplitude was the difference between the
fitted curve’s maximum and minimum. Although some subjects were studied during
daylight savings time, all times are reported in central standard time.
Each variable was evaluated with a one-way analysis of variance (ANOVA) with the
factor group (women in the follicular phase, women in the luteal phase, women in the
pseudofollicular phase, women in the pseudoluteal phase, men) followed by Tukey’s
post hoc painvise comparisons of means. The same variables in only the four groups of
women were also evaluated with a two-way ANOVA with the factors OC use (yes, no)
and menstrual phase (follicular, luteal).
RESULTS
The data from 50 male and 35 female subjects were analyzed (see Table I ) . For illustrative
purposes only, the average temperature curves of the individual subjects were
averaged together to produce average curves for the five groups of subjects (Figs. 1 and
2). These graphs were made from raw (as opposed to fitted) data. The graphs show that
the differences among the groups were most pronounced at night, during sleep.
Temperature Level
The two-way ANOVA produced a significant main effect of menstrual phase for temperature
during sleep (F = 24.182, df= 1,3 I , p < 0.001) and for 24-h temperature ( F =
13.959, df= 1,3 I , p < 0.0 1) and a significant main effect of OC use for temperature
during sleep (F= 14.476, df= 1,3 1, p < 0.01) and for 24-h temperature (F= 10.372, df’
= 1,3 I, p < 0.01). There were no significant two-way interactions. These analyses showed
that temperature was significantly lower during the follicular phase than during the
luteal phase. The analyses also showed that temperature was significantly lower in non-
OC users than in OC users.
The one-way ANOVA was significant for temperature during sleep (F = 47.08 I , df
= 4,80, p < 0.001) and 24-h temperature (F= 23.971, df= 4,80, p < 0.001). There were
two groups that had similar temperature levels and differed from the other three: women
non-OC users in the follicular phase and men. They had the lowest temperatures during
sleep and the lowest 24-h temperatures. The post hoc tests showed that the differences
in temperature level between each of these two groups and the other three groups
were statistically significant (see Table 2). It is also interesting to note that although
there were no significant differences between OC users and nonusers during the luteal
phase, there was a significant difference between them during the follicular phase, with
the nonusers having lower temperatures.
Temperature Amplitude
The two-way ANOVA produced a significant main effect of menstrual phase (F =
1 1.322, dj= 1,3 1, p < O.Ol), but the main effect for OC use and the two-way interaction
were not significant. This analysis showed that amplitude was larger during the follicular
than during the luteal phase.
The one-way ANOVA was significant (F = 13.326, df= 4,80, p < 0.001). There were
two groups that had similar and larger temperature amplitudes than the other three
groups: women non-OC users in the follicular phase and men. The differences between
the men and each of the other three groups of women were statistically significant. The
differences between the women non-OC users in the follicular phase and the other three
groups of women reached significance for two of the three groups.
Temperature Phase
Temperature minima occurred around 5 a.m., -3 h before wake time .
There were no significant differences in time of temperature minima, in time of temperature
minima in relation to wake time, or in wake times.
Amplitude and Level: Comparisons Among Women
This report confirms previous studies of women that found luteal phase temperature
levels to be elevated, particularly during sleep, which in turn produced a smaller circadian
amplitude during the luteal phase (3,8-13). The increase in temperature levels during
the luteal phase is attributed to the thermogenic effect of progesterone (4-6). However,
it is not clear why the progesterone-induced temperature elevation would be greater
during sleep. Rogacz et al. (3) discussed the idea that temperature levels might be limited
by a physiologic ceiling that prevents the already high day time temperatures from
increasing past a certain point, so that only the lower nocturnal temperatures can rise.
They also suggested that progesterone might act directly on the endogenous pacemaker
to reduce amplitude. Another possibility could be that the effects of progesterone,
like those of drugs in general, depend on circadian phase. In other words, progesterone
might produce a larger rise in body temperature during one part of the circadian cycle
than another.
The increase in temperature level at the transition from the follicular to the luteal
phase is the basis for using basal body temperature as a marker of ovulation (23). However,
Fig. l reminds us that the term “basal” can be misleading, since temperature does
not remain constant during inactivity or sleep, but instead has a circadian rhythm. This
figure also shows how much the temperature recorded on waking in the morning could
change if the woman woke up earlier or later than usual, i.e., at an earlier or later point
on the temperature curve.
We found that women OC users had higher temperatures during the pseudofollicular
phase than women with natural menstrual cycles during their follicular phase. Progesterone
cannot be responsible for this difference because both groups have low levels
during their follicular phases. However, the naturally cycling women produce estrogens,
which can be high near the end of the follicular phase. Therefore, estrogen is probably
exerting a temperature-lowering effect (24). Lee (10) also reported relatively high temperatures
during the follicular phase in three OC users. Evidently, there is a need for
more research to determine how exogenously administered hormones affect body temperature
rhythms.
Higher temperatures during sleep could conceivably cause or be a result of poorer
sleep quality (25). Our data are not ideal for detecting differences in sleep duration,
because all subjects were required to remain in bed in the dark for exactly 8 h. Furthermore,
we did not have a measure that could reveal fine distinctions in sleep quality.
There is some evidence of sleep disturbance during the luteal phase (see 26 for
review), but more research is necessary to determine whether endogenous or exogenously
administered hormones affect sleep.
Amplitude and Level: Comparisons Between Men and Women
In this study, the women with natural menstrual cycles (non-OC users) who were in
the follicular phase had circadian temperature rhythms that resembled the men’s more
than they resembled those of the other groups of women. This group of women and the
men had the lowest temperatures during sleep, and consequently the lowest 24-h temperatures
and largest circadian amplitudes. The low temperatures in these two groups
are consistent with both having little or no circulating progesterone. In contrast, Rogacz
et al. (3) reported that women in both the follicular and the luteal phases had smaller
amplitudes than men. The other studies that compared temperature rhythms in men and
women did not account for menstrual phase ( I ,2). Thus, further research is necessary
to clarify the differences in temperature rhythm amplitude and temperature level between
men and women. Future studies should also take possible sex differences in physical
fitness into account, since larger temperature rhythm amplitudes have been found in
very physically fit than in inactive or average men, even when the temperature rhythm
was measured during standardized conditions (27,28).
Temperature Phase
We did not find any differences in the phase of the circadian rhythm of temperature
among the various groups of subjects. The only other study we know of that compared
temperature rhythms in young men and women also did not find a phase differcnce (1).
Studies of temperature phase in women across the menstrual cycle are more common.
Most found no phase differences ( 10,11,15,16), but two suggest a phase delay during
the luteal phase (9,13). In both of these studies, the data were collected during a constant
routine using a within-subject design. These methodological refinements may be
necessary to reveal phase differences. However, Wagner et al. ( 16) used both a constant
routine and a within-subject design, but did not find phase differences. More research
is necessary to resolve the issues of whether temperature phase changes with the menstrual
cycle and whether there is a sex difference. The use of other phase markers of the
circadian pacemaker besides the temperature rhythm would also help to clarify the issue.
However, there have been two studies using the circadian rhythm of melatonin, and these
did not reveal phase changes across the menstrual cycle (29,30).
The time of the minimum of the circadian temperature rhythm is currently of great
interest, because it is used as a marker of the crossover point between delays and advances
in the human phase response curve to light (e.g., 3 1,32). Thus, the clock time of the
minimum is important for practical applications of light treatment (e.g., 33). Constant
routine methods (3 1,34) may provide the most accurate measure of the temperatiire minimum
and are good for measuring the phase shift in situations in which the endogenous
temperature minimum does not occur during sleep and is thus subject to masking, e.g.,
during shift work. However, it is not clear whether the constant routine method offers
any benefit for determining the temperature minimum of normal subjects sleeping at
normal times. A few studies compared temperature phase measured during a constant
routine with those obtained during days with normal sleep. Two found no difference in
phase ( 1 3,35), one found a slightly later phase (36), and one found a slightly earlier
phase (37) during the constant routine. In our study, the clock times of the temperature
minima were similar to those from constant routine studies: For men: our study-5: 18;
constant routine studies4:31 to 5:02 (38), 5:19 (39), and 6:48 (40). For women not
taking OC: our study-5:06 in the follicular stage and 4:36 in the luteal stage; constant
routine s t u d y 4 : 18 during the follicular phase and 4:27 during the luteal phase ( 16).
Some of the variations in the time of the temperature minimum within and between
studies are undoubtedly due to factors such as individual differences in niorningnesseveningness
(4 1 ), previous sleep schedules, and daylight exposure schedules. For example,
in a previous study of ours in which wake times were -2 h earlier than in the present
study, the temperature minima were also -2 h earlier (42). Variations in the time
of the temperature minimum are also produced by the different methods for determining
the minimum, such as cosine curve fitting, smoothing procedures, visually picking
the minimum, etc. Another complication is daylight savings time. Most authors do not
indicate whether times are reported in daylight savings or standard time. It seems likely
that these factors are more important determinants of circadian phase than sex or
menstrual cycle phase.
In conclusion, more research is needed to compare the circadian temperature rhythms
of women in their various hormonal states and men. Meanwhile, our study of temper
ature rhythms shows that although sex, menstrual cycle phase, and contraceptive use
influence temperature rhythm amplitude and level, these factors may not have a significant
influence on temperature phase.