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After the September 11 terrorist attacks, Americans experienced symptoms of psychological stress. This survey of U.S. adults performed just five days after the attacks quantifies the extent of the stress reactions. The terrorist attacks against the United States on September 11, 2001, shook the nation. Television coverage was immediate, graphic, and pervasive. 1 – 3 Newscasts included remarkable video footage showing two airplanes crashing into the World Trade Center and the aftermath of four airplane crashes. 2 , 3 People who are present at a traumatic event often have symptoms of stress, but there is evidence that adults and children need not be present to have stress symptoms, 4 – 6 especially if they consider themselves similar to the victims. 4 The events on September 11 were widely described as attacks on America, and most or all Americans . . .

ABSTRACT BACKGROUND The health and healthcare of sexual minorities have recently been identified as priorities for health research and policy. OBJECTIVE To compare the health and healthcare experiences of sexual minorities with heterosexual people of the same gender, adjusting for age, race/ethnicity, and socioeconomic status. DESIGN Multivariate analyses of observational data from the 2009/2010 English General Practice Patient Survey. PARTICIPANTS The survey was mailed to 5.56 million randomly sampled adults registered with a National Health Service general practice (representing 99 % of England’s adult population). In all, 2,169,718 people responded (39 % response rate), including 27,497 people who described themselves as gay, lesbian, or bisexual. MAIN MEASURES Two measures of health status (fair/poor overall self-rated health and self-reported presence of a longstanding psychological condition) and four measures of poor patient experiences (no trust or confidence in the doctor, poor/very poor doctor communication, poor/very poor nurse communication, fairly/very dissatisfied with care overall). KEY RESULTS Sexual minorities were two to three times more likely to report having a longstanding psychological or emotional problem than heterosexual counterparts (age-adjusted for 5.2 % heterosexual, 10.9 % gay, 15.0 % bisexual for men; 6.0 % heterosexual, 12.3 % lesbian and 18.8 % bisexual for women; p  < 0.001 for each). Sexual minorities were also more likely to report fair/poor health (adjusted 19.6 % heterosexual, 21.8 % gay, 26.4 % bisexual for men; 20.5 % heterosexual, 24.9 % lesbian and 31.6 % bisexual for women; p  < 0.001 for each). Adjusted for sociodemographic characteristics and health status, sexual minorities were about one and one-half times more likely than heterosexual people to report unfavorable experiences with each of four aspects of primary care. Little of the overall disparity reflected concentration of sexual minorities in low-performing practices. CONCLUSIONS Sexual minorities suffer both poorer health and worse healthcare experiences. Efforts should be made to recognize the needs and improve the experiences of sexual minorities. Examining patient experience disparities by sexual orientation can inform such efforts.

Background: Patient activation status (PAS) can be identified using the Medicare Segmentation Screening Tool, a 2-item measure assessing patients' health skills and motivation to participate in their own care. Objective: To determine whether PAS is predictive of Medicare beneficiary health care experiences with health providers and insurance plans after case-mix adjustment. Research Design: Linear regression models examined the association between PAS and evaluations of care after case-mix adjustment in observational cross-sectional data. Subjects: 236,322 Medicare beneficiaries with at least one prescription medication responding to the Medicare Segmentation Screening Tool items on the 2007 Medicare Consumer Assessment of Healthcare Providers and Systems Survey. Measures: Four-category patient activation category; 11 patientreported evaluations of health care and providers and 2 self- reported immunization measures. Results: PAS was strongly predictive of beneficiary experience beyond case-mix adjustment. Even after case-mix adjustment, active beneficiaries consistently reported the most positive experiences, followed by complacent beneficiaries, with differences of 0.2 to 0.4 standard deviations for 4 of 5 composite measures of patient experience (P < 0.05). Adjusted immunization rates for flu and pneumonia were highest for active beneficiaries, followed closely by high- effort beneficiaries. The rates for these 2 segments were 10 percentage points higher than for complacent and passive beneficiaries. Conclusions: PAS may be an important determinant of health care experiences. More confident respondents (active and complacent) give higher ratings of their care and providers, suggesting that they have more favorable experiences. Respondent motivation (high for active and high effort) seems to be a factor in receiving preventive care.

In this study of public-school fifth-graders in three U.S. metropolitan areas, black children and Latino children were more likely than white children to report harmful health behaviors, experiences, and outcomes. Most health disparities appeared to be mediated by socioeconomic status and the child's school. Substantial racial and ethnic disparities have been documented among adolescents across a range of health-related behaviors, experiences, and outcomes, including the use of bike helmets 1 ; witnessing of violence, experience of victimization, and perpetration of violence 1 – 6 ; experience of discrimination 7 ; perceived health status 8 , 9 ; and obesity. 1 – 3 , 8 , 10 , 11 In contrast, we know much less about similar health-related issues among preadolescents. Several studies in this age group, which generally have involved small numbers of participants, examined one or two health behaviors, or included only two racial and ethnic groups, suggest that disparities among these children may . . .

Patients' comments about doctors are increasingly available on the internet. The effects of these anecdotal accounts on consumers' engagement with reports on doctor quality, use of more statistically reliable performance measures, and ability to choose doctors wisely are unknown. To examine the effects of providing patient comments along with standardized performance information in a web-based public report. Participants were randomly assigned to view 1 of 6 versions of a website presenting comparative performance information on fictitious primary care doctors. Versions varied by the combination of information types [Consumer Assessment of Healthcare Providers and Systems (CAHPS), Healthcare Effectiveness Data and Information Set (HEDIS), and patient comments] and number of doctors. A random sample of working-age adults (N=848) from an online panel representing the noninstitutionalized population of the United States. Time spent and actions taken on the website, probing of standardized measures, and decision quality (chosen doctor rated highest on quantifiable metrics, chosen doctor not dominated by another choice). Secondary outcomes were perceived usefulness and trustworthiness of performance metrics and evaluations of the website. Inclusion of patient comments increased time spent on the website by 35%-42% and actions taken (clicks) by 106%-117% compared with versions presenting only CAHPS and HEDIS measures (P<0.01). It also reduced participants' attention to standardized measures (eg, percentage of time probing HEDIS measures dropped by 67%, P<0.01). When patient comments were present, fewer participants chose the doctor scoring highest on standardized metrics (44%-49% vs. 61%-62%, P<0.01). Including patient comments in physician performance reports enhances consumers' engagement but reduces their attention to standardized measures and substantially increases suboptimal choices. More research is needed to explore whether integrated reporting strategies could leverage the positive effects of patient comments on consumer engagement without undermining consumers' use of other important metrics for informing choice among doctors.

HIV-related stigma and mistrust contribute to HIV disparities. Addressing stigma with faith partners may be effective, but few church-based stigma reduction interventions have been tested. We implemented a pilot intervention with 3 Latino and 2 African American churches (4 in matched pairs) in high HIV prevalence areas of Los Angeles County to reduce HIV stigma and mistrust and increase HIV testing. The intervention included HIV education and peer leader workshops, pastor-delivered sermons on HIV with imagined contact scenarios, and HIV testing events. We surveyed congregants at baseline and 6 month follow-up (n = 1235) and found statistically significant (p < 0.05) reductions in HIV stigma and mistrust in the Latino intervention churches but not in the African American intervention church nor overall across matched African American and Latino pairs. However, within matched pairs, intervention churches had much higher rates of HIV testing (p < 0.001). Stigma reduction and HIV testing may have synergistic effects in community settings.

Objectives. We sought to describe the prevalence, characteristics, and mental health problems of children who experience perceived racial/ethnic discrimination. Methods. We analyzed cross-sectional data from a study of 5147 fifth-grade students and their parents from public schools in 3 US metropolitan areas. We used multivariate logistic regression (overall and stratified by race/ethnicity) to examine the associations of sociodemographic factors and mental health problems with perceived racial/ethnic discrimination. Results. Fifteen percent of children reported perceived racial/ethnic discrimination, with 80% reporting that discrimination occurred at school. A greater percentage of Black (20%), Hispanic (15%), and other (16%) children reported perceived racial/ethnic discrimination compared with White (7%) children. Children who reported perceived racial/ethnic discrimination were more likely to have symptoms of each of the 4 mental health conditions included in the analysis: depression, attention deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder. An association between perceived racial/ethnic discrimination and depressive symptoms was found for Black, Hispanic, and other children but not for White children. Conclusions. Perceived racial/ethnic discrimination is not an uncommon experience among fifth-grade students and may be associated with a variety of mental health disorders.

Objectives. We examined the contribution of perceived racial/ethnic discrimination to disparities in problem behaviors among preadolescent Black, Latino, and White youths. Methods. We used cross-sectional data from Healthy Passages, a 3-community study of 5119 fifth graders and their parents from August 2004 through September 2006 in Birmingham, Alabama; Los Angeles County, California; and Houston, Texas. We used multivariate regressions to examine the relationships of perceived racial/ethnic discrimination and race/ethnicity to problem behaviors. We used values from these regressions to calculate the percentage of disparities in problem behaviors associated with the discrimination effect. Results. In multivariate models, perceived discrimination was associated with greater problem behaviors among Black and Latino youths. Compared with Whites, Blacks were significantly more likely to report problem behaviors, whereas Latinos were significantly less likely (a “reverse disparity”). When we set Blacks’ and Latinos’ discrimination experiences to zero, the adjusted disparity between Blacks and Whites was reduced by an estimated one third to two thirds; the reverse adjusted disparity favoring Latinos widened by about one fifth to one half. Conclusions. Eliminating discrimination could considerably reduce mental health issues, including problem behaviors, among Black and Latino youths.

Background: Patients are hospitalized for disparate conditions and procedures. Patient experiences with care may depend on hospitalization type (HT). Objectives: Determine whether the contributions of patient experience composite measures to overall hospital ratings on the Hospital Consumer Assessment of Healthcare Providers and Systems Survey vary by HT. Research Design: In cross-sectional observational data, we defined 24 HTs using major diagnostic category and service line (medical, surgical, or obstetrical). To assess the importance of each composite for each HT, we calculated the simultaneous partial correlations of 7 composite scores with an overall hospital rating, controlling for patient demographics. Subjects: Nineteen thousand seven hundred twenty English-or Spanish-speaking adults with nonpsychiatric primary diagnoses discharged home 12/02-1/03 after an overnight inpatient stay in any of 132 general acute care hospitals in 3 states. Measures: Patient- reported doctor communication, nurse communication, staff responsiveness, physical environment, new medicines explained, pain control, and postdischarge information; overall 0 to 10 rating of care. Results: Nurse communication was most important overall, with a 0.34 average partial correlation (range: 0.17-0.49; P < 0.05 and among the 3 most important composites for all HTs). Discharge information was least important (0.05 average partial correlation; P < 0.05 for 10 of 24 HTs). Interactions demonstrated significant (P < 0.05) variation in partial correlations by HT for 5 of 7 composites (all but responsiveness and environment), with nurse communication, doctor communication, and pain control showing the most variation (F > 2, P < 0.05). Conclusions: The importance of patient experience dimensions differs substantially and varies by HT. Quality improvement efforts should target those aspects of patient experience that matter most for each HT.

Many young adolescents are dissatisfied with their body due to a discrepancy between their ideal and actual body size, which can lead to weight cycling, eating disorders, depression, and obesity. The current study examined the associations of parental and peer factors with fifth-graders’ body image discrepancy, physical self-worth as a mediator between parental and peer factors and body image discrepancy, and how these associations vary by child’s sex. Body image discrepancy was defined as the difference between young adolescents’ self-perceived body size and the size they believe a person their age should be. Data for this study came from Healthy Passages, which surveyed 5,147 fifth graders (51 % females; 34 % African American, 35 % Latino, 24 % White, and 6 % other) and their primary caregivers from the United States. Path analyses were conducted separately for boys and girls. The findings for boys suggest father nurturance and getting along with peers are related negatively to body image discrepancy; however, for girls, fear of negative evaluation by peers is related positively to body image discrepancy. For both boys and girls, getting along with peers and fear of negative evaluation by peers are related directly to physical self-worth. In addition, mother nurturance is related positively to physical self-worth for girls, and father nurturance is related positively to physical self-worth for boys. In turn, physical self-worth, for both boys and girls, is related negatively to body image discrepancy. The findings highlight the potential of parental and peer factors to reduce fifth graders’ body image discrepancy.