Including Risk Behaviors Research Articles

Empowering People Experiencing Homelessness for cancer prevention using the Health Navigator Model

Abstract Cancer poses a significant public health concern. Reports highlight that cancer-related mortality rates are double among people experiencing homelessness (PEH). CANCERLESS project delivered an innovative solution based on the Health Navigator Model (HNM). The HNM is an evidence-based patient-centred intervention that develops patient empowerment through health education and social support, promoting timely access to cancer prevention services. A pre-post design study conducted across four pilot sites in Europe (Austria, Greece, Spain, UK) involved 652 PEHs. Pilot interventions based on the HNM were implemented, with effectiveness evaluated at baseline and post-intervention. The study assessed the impact of the HNM on various factors including risk behaviors, lifestyles, quality of life, empowerment, health literacy, psychological distress and utilization of health and care services. Preliminary findings from CANCERLESS HNM intervention showed significant improvements (p= .000) in participants’ quality of life (55.82 (27.65) vs. 66.18 (22.27)) and sense of empowerment (25.58 (19.95) vs. 59.94 (43.10)). However, there were no observable impacts in health literacy (p= .509) or psychological distress (p= .140), which remained within acceptable ranges both pre- and post-intervention. Similarly, there were no significant changes observed in lifestyle or risk behaviours among PEHs. Nonetheless, the evaluation of effectiveness suggested that the HNM increase in the uptake of cancer prevention care, such as cancer screening (p= .000). The CANCERLESS HNM intervention significantly improved the quality of life and empowerment of PEHs. Additionally, it successfully promoted their involvement in cancer prevention efforts, addressing disparities in access to preventive healthcare services. Increased engagement in such initiatives can lead to early detection and treatment, ultimately reducing cancer morbidity and mortality rates, thereby positively impacting public health. Key messages • By promoting health equity and social justice, interventions like CANCERLESS HNM contribute to building healthier and more resilient public health systems. • CANCERLESS boosts cancer prevention awareness, tackles healthcare disparities, enhances cancer early detection, benefiting public health.

Alcohol Misuse Among Youth Living With and at High Risk for Acquiring HIV During the COVID-19 Stay-at-Home Orders: A Study in Los Angeles and New Orleans.

To slow the spread of the COVID-19 virus, governments across the globe instituted stay-at-home orders leading to increased stress and social isolation. Not surprisingly, alcohol sales increased during this period. While most studies primarily focused on alcohol consumption among college students or adults, this study investigates alcohol misuse among marginalized youth in the USA. We examined risk factors associated with hazardous alcohol use and binge drinking including risk behaviors, life stressors and demographic characteristics. In October 2020, youth living with or at high risk for acquiring human immunodeficiency virus (HIV), participating in community-based research to improve HIV prevention and care, were invited to complete an online survey to assess the impact of the stay-at-home orders on multiple aspects of their daily life. Respondents (n = 478) were on average 23years old; cisgender (84%), not-heterosexual (86.6%), Latino or Black/African American (73%) and assigned male at birth (83%); 52% reported being employed and 14% reported living with HIV. White participants and those who use drugs had higher odds of hazardous alcohol use and binge drinking, compared with other race categories and non-drug users, respectively. Contrary to findings from adult studies, we did not observe an increase in hazardous or binge drinking among youth at risk for HIV. Hazardous alcohol use and binge drinking was more likely among White participants, those who use drugs and those who were hazardous/binge drinkers prior to the COVID-19 lockdown, which points to the importance of identifying and treating youth who misuse alcohol early to prevent future alcohol misuse.

Editors' Selections from Relevant Scientific Publications

Editors' Selections from Relevant Scientific Publications

Short- and Long-Term Effects of Superhero Media on Young Children's Risk-Taking Behaviors.

Unintentional injuries, the leading cause of death for American children, are caused by a range of psychosocial factors, including risk behavior. One factor that may impact child risk-taking is modeling of superhuman risk-taking from superhero media, both immediately following superhero exposure and based on lifetime exposure and engagement. Fifty-nine 5-year-olds were randomly assigned to view either a 13-min age-appropriate superhero television show or a comparable nonsuperhero show. After the viewing, children engaged in three risk-taking measures: (a) activity room, unsupervised play for 5 min with assortment of apparently dangerous items that might encourage child risk-taking; (b) picture sort, 10 illustrations of children in risk situations, with participant response concerning intended risk-taking in that situation; and (c) vignettes, 10 stories presenting situations with varying degrees of risk, with participant response on intended choice. Parents completed questionnaires concerning children's long-term superhero media exposure and individual superhero engagement (e.g., if child's most recent Halloween costume was of a superhero). Correlations and regressions evaluated effects of immediate superhero exposure, lifetime superhero exposure, and lifetime superhero engagement on children's risk-taking. Mixed results emerged. Lifetime superhero exposure was significantly related to children's risk-taking outcomes in two bivariate (vignettes and picture sort) and one multivariate (picture sort) model. Neither immediate superhero exposure nor lifetime superhero engagement was strongly related to risk-taking. Children's lifetime superhero exposure may influence children's risk-taking. Given American children's substantial media exposure, research should continue to unpack the role of superhero media on children's unintentional injury and other health risk behaviors.

Analysis of Health Behavior of Adolescents in Tuban, Indonesia

Adolescence is a period associated with increased risk behaviors such as smoking, sex, fighting, the use ofsharp weapons and so on. These conditions coincide with changes in social and school environment. Thepurpose of this study is to explain how health risk behaviors are to adolescents. The research design usedin this study was analytic with a cross sectional approach. The population was all high school/vocationalschool adolescents with a total of 29,963 boys and girls, with a sample size of 395 using cluster samplingtechnique. The independent variable of the study is risk behavior and the dependent variables of the studyare smoking, bullying, use of sharp weapons, driving, drug consumption, sex, health consultation, nutritionalfulfillment, suicide attempt, alcohol consumption, fighting and physical activity. Data collection was carriedout using a questionnaire adopted from YRBSS (Youth Risk Behavior Surveillance System) which wastranslated into Indonesian. The collected data was tabulated and analyzed using Logistic Regression. Theresults showed that all health behavior including risk behaviors, although based on statistical test resultsthe behavior of alcohol and drug consumption was not significant because (p value) was 0.000>0.005.Smoking behavior had a regression coefficient of 6,904 with a significance level (p value) of 0.000<0.005and an OR (odds ratio) of 996,365, which means that adolescents have 996 times the chance to smoke. Allvariables are included in health risk behaviors; however, smoking is the riskiest health behavior carried outby adolescents

316. Hepatitis C and Engagement in Health Care Among Persons Who Inject Drugs and Persons Who Use Non-Injection Drugs, Philadelphia

BackgroundThe growing opioid epidemic is driving increasing rates of hepatitis C virus (HCV) infections in the United States. HCV transmission is most frequently attributed to unsafe injection behaviors, but can occur via other unsafe drug use and sexual behaviors. Differences in demographics, HCV rates and associated risk factors in non-injecting PWUD (NIPWUD), compared with people who inject drugs (PWID) must be understood in order to target elimination strategies.MethodsChange is Philadelphia’s program to eliminate HCV among PWUD and enrollment includes HCV testing, linkage services, and an interviewer-administered survey including risk behaviors and healthcare engagement. This interim analysis includes the first 835 enrollees that identified as PWUD. For this analysis, PWID are enrollees who indicated ever injecting drugs and those who had not are NIPWUD.ResultsAmong enrollees, 76% (N = 637) reported ever injecting drugs. PWIDs were younger and non-Hispanic (NH) white while NIPWUD were older and NH Black (age: P = 0.003; race/ethnicity: P < 0.0001). NIPWUDs had a high seropositivity rate though significantly lower than PWIDs (24% vs. 85%, respectively; P < 0.0001). Among PWID enrollees, 94% (N = 596) ever snorted. Of enrollees, 63% (N = 124) of NIPWUD and 56% (N = 356) of PWID identified having a PCP (P =0.07). PWIDs are more likely than NIPWUD to have overdosed (OD) (40% vs. 9%; P < 0.0001) though high rates of both groups ever witnessed an OD (84% vs. 67%, respectively). While 80% (N = 105) of NIPWUDs know how to use Narcan, 60% (N = 79) carry it, {94% (N = 503) and 71%(N = 381) in PWID, respectively}. NIPWUDs are more likely to be interested in drug treatment (P < 0.0001) and to have received it in the last 12 months (P = 0.0008).ConclusionNotable HCV infection exists among non-injecting PWUD reinforcing the need for harm reduction counseling and access to drug use equipment used for smoking and snorting. NIPWUD may be able to access drug and HCV treatment through PCPs and fatal ODs may be prevented by ensuring NIPWUDs have access to Narcan. In addition, PWID are likely to snort as well and should be counseled on non-injecting harm reduction methods. To succeed in micro elimination among PWUD, a focus on NIPWUDs as well as PWIDs is necessary to mitigate transmission of HCV.Disclosures All authors: No reported disclosures.

Depression among Patients with HIV/AIDS: Research Development and Effective Interventions (GAPRESEARCH).

Depression in people living with HIV (PLWH) has become an urgent issue and has attracted the attention of both physicians and epidemiologists. Currently, 39% of HIV patients are reported to suffer from depression. This population is more likely to experience worsening disease states and, thus, poorer health outcomes. In this study, we analyzed research growth and current understandings of depression among HIV-infected individuals. The number of papers and their impacts have been considerably grown in recent years, and a total of 4872 publications published from 1990–2017 were retrieved from the Web of Science database. Research landscapes related to this research field include risk behaviors and attributable causes of depression in HIV population, effects of depression on health outcomes of PLWH, and interventions and health services for these particular subjects. We identified a lack of empirical studies in countries where PLWH face a high risk of depression, and a modest level of interest in biomedical research. By demonstrating these research patterns, highlighting the research gaps and putting forward implications, this study provides a basis for future studies and interventions in addressing the critical issue of HIV epidemics.

The Impact of Family-Centered Prevention on Self-Regulation and Subsequent Long-Term Risk in Emerging Adults.

Emerging adulthood is characterized by not only opportunity and transition but also a substantial increase in risk behaviors (Fosco et al. Journal of Family Psychology, 26(4), 565-575, 2012; Johnston et al. 2016). Building on prior research, we tested a mediational model hypothesizing that Family Check-Up (FCU) intervention effects on young adult risk would be mediated by increases in self-regulation, and that these changes would continue to affect risk behavior as high school youths transitioned to young adulthood. We also predicted that the intent-to-treat intervention would be associated with lower levels of risk in young adulthood and that this effect would be accounted for by intervention-induced improvements in self-regulation during early adolescence, which in turn would prevent young adult risk. Participants were 593 adolescents and their families recruited from three public middle schools and randomized either to the FCU or to a control group. Item response theory was applied to construct a measure of high-risk behavior at this age, including risk behaviors such as substance abuse, high-risk sexual behavior, and vocational risk. Results suggested that changes in children's self-regulation that occurred early during the middle school years, and that were associated with the FCU, led to reductions in risk behaviors during young adulthood. This study builds on our prior research that has suggested that effects of the FCU during middle school lead to changes in a range of risk behaviors during the transition to high school (Fosco et al. Journal of School Psychology, 51(4), 455-468, 2013; Stormshak et al. School Mental Health, 2(2), 82-9, 2010).

Understanding Strengths in Relation to Complex Trauma and Mental Health Symptoms within Child Welfare

Strengths can have a potent effect in mitigating the impact of trauma on mental health needs and functioning. Yet, evidence is limited on the role that strengths may have in ameliorating trauma-related or mental health symptoms over time. Providing a comprehensive assessment that includes strengths, as well as needs, is an important step in making appropriate service recommendations for youth in child welfare. This study assessed 7,483 children and adolescents entering an intensive stabilization program through the Illinois child welfare system. The interaction of individual, child strengths in relation to complex trauma exposure, traumatic stress symptoms, risk behaviors, and other mental health needs were examined. Results indicated strengths are relatively stable over time and inversely associated with several negative outcomes, including risk behaviors (−.32, p < .001), emotional/ behavioral needs (−.33, p < .001) and overall functioning (−.47, p < .001). Traumatic stress symptoms were also related to increases in these negative outcomes. Overall, strengths had a buffering effect on traumatic stress symptoms and outcomes over time. The role of strengths in relation to traumatic stress symptoms, however, was less consistent. Youth with histories of complex trauma exposure had significantly fewer useable strengths than youth without this exposure. However, strengths improved for both youth with and without complex trauma exposure over the course of stabilization services. These findings suggest that early identification and development of child strengths can mitigate risk-taking behaviors, mental health, and functional difficulties among youth in the child welfare system. Implications for more targeted trauma-informed and strengths-based assessment, and treatment/service planning are discussed.

A qualitative investigation comparing sexual effects of alcohol and marijuana among adults

Aims: Alcohol andmarijuana (cannabis) are the twomost commonly used psychoactive drugs and each appears to have its own unique sexual effects on users. With marijuana use increasing in the United States, along with more liberal state-level policies, it is important to examine and compare sexual effects and sexual risk behavior associated with these drugs in order to inform prevention of HIV, other sexually transmitted infections and unplanned pregnancy. Methods: We conducted semi-structured interviews with 24 racially and ethnically diverse adults in New York City (mean age=27.4, SD=5.8). To be eligible, subjects must have (1) been between ages 18–35, (2) had sex while high on marijuana in the last 12 months, (3) had sex while not high on marijuana in the last 12 months; and (4) must not have used any other illicit drug in the last 12 months. All subjects self-identified as heterosexual and HIV-negative, and 50% were female. Results: Thematic analysis yielded various themes. Many subjects described differences between the two drugs with regard to interactions and contexts in use before sex, partner choice, perceived attractiveness of self and others, disinhibition, adverse sexual effects and sexual dysfunction, and dose effects. Differences were also commonly described regarding libido, length and intensity of sex and orgasm, specific sexual behaviors (including risk behavior), and feelings such as regret after sex. Compared to marijuana, alcohol was more likely to be associated with atypical partner choice and lead to regret. Illegality ofmarijuana sometimes facilitated intimate encounters. Conclusions: Results can inform prevention efforts regarding specific sexual risks and allow us to design more realistic prevention programs and interventions to guide potential users to make safer choices. Financial support: This pilot study was funded by the Center for Drug Use and HIV Research (P30DA011041).

Moderators of electronic screening and brief intervention for marijuana among students in a health center: eCHECKUP TO GO bolsters efforts of those who are already trying to change

Aims: Alcohol andmarijuana (cannabis) are the twomost commonly used psychoactive drugs and each appears to have its own unique sexual effects on users. With marijuana use increasing in the United States, along with more liberal state-level policies, it is important to examine and compare sexual effects and sexual risk behavior associated with these drugs in order to inform prevention of HIV, other sexually transmitted infections and unplanned pregnancy. Methods: We conducted semi-structured interviews with 24 racially and ethnically diverse adults in New York City (mean age=27.4, SD=5.8). To be eligible, subjects must have (1) been between ages 18–35, (2) had sex while high on marijuana in the last 12 months, (3) had sex while not high on marijuana in the last 12 months; and (4) must not have used any other illicit drug in the last 12 months. All subjects self-identified as heterosexual and HIV-negative, and 50% were female. Results: Thematic analysis yielded various themes. Many subjects described differences between the two drugs with regard to interactions and contexts in use before sex, partner choice, perceived attractiveness of self and others, disinhibition, adverse sexual effects and sexual dysfunction, and dose effects. Differences were also commonly described regarding libido, length and intensity of sex and orgasm, specific sexual behaviors (including risk behavior), and feelings such as regret after sex. Compared to marijuana, alcohol was more likely to be associated with atypical partner choice and lead to regret. Illegality ofmarijuana sometimes facilitated intimate encounters. Conclusions: Results can inform prevention efforts regarding specific sexual risks and allow us to design more realistic prevention programs and interventions to guide potential users to make safer choices. Financial support: This pilot study was funded by the Center for Drug Use and HIV Research (P30DA011041).

Cross-National Perspectives on Early Adolescence

The current special issue brings together intriguing and important cross-country comparisons of issues pertinent to early adolescence that can inform the design and implementation of broader and relevant public health prevention strategies. The findings illustrate the importance of cross-country analyses for better understanding a range of health-related factors, including risk behaviors, mental health concerns, life satisfaction, and parent–child communication and relationships. The findings also underscore the convergence across countries and cultures of risk and protective factors as well as their associations with adverse health outcomes. Taken as a whole, the findings demonstrate that there are different unmet needs among girls and boys. As such, the findings stress the importance of providing youth with targeted prevention approaches and also, where feasible, sex-specific prevention and intervention strategies to direct scarce resources where they are most urgently needed.

Questionnaire-Related Deferrals in Regular Blood Donors in Norway

Voluntary donation is a key issue in transfusion medicine. To ensure the safety of blood transfusions, careful donor selection is important. Although new approaches to blood safety have dramatically reduced the risks for infectious contamination of blood components, the quality and the availability of blood components depend on the willingness to donate and the reliability of the information given by the donors about their own health, including risk behavior. As donors who are deferred by the blood bank will be less motivated to return for donation, it is important to reduce the number of deferrals. The aims of the present study were to investigate the reasons for deferral of registered donors coming to the blood bank for donation, in order to identify areas of importance for donor education—as these deferrals potentially could be avoided by better donor comprehension. Deferral related to testing of donors is not included in this study as these deferrals are dependent on laboratory results and cannot be indentified by questionnaire or interview. Data were collected from all blood donors in a period for 18 months who came for blood donation at a large university hospital in Norway. 1 163 of the 29 787 regular donors, who showed up for donation, were deferred (3.9%). The main reasons were intercurrent illness (n = 182) (15.6%), skin ulcers (n = 170) (14.6%), and risk behaviour (n = 127) (10.9%). In a community, intercurrent illnesses, skin ulcers, and potential risk behavior are the most frequent reasons for deferral of regular donors. Strategized effort on donor education is needed, as “failure to donate” reduces donor motivation.

Spousal caregiving and incident hypertension

Caring for one's spouse has been associated with poor health, including risk of cardiovascular disease (CVD) onset and mortality. However, few studies have assessed the risk of incident hypertension associated with spousal caregiving. This paper investigates this association in a large, nationally representative sample of American older adults. Married, hypertension-free, Health and Retirement Study (HRS) respondents aged 50+ in 2000, (n = 5,708) were followed up to 8 years (1,708 new self-reported hypertension diagnoses). Current caregiving exposure was defined as assisting a spouse with instrumental or basic activities of daily living (IADLs) 14+ h/week; we define providing ≥14 h/week of care at two consecutive biennial surveys as "long-term caregiving." We used inverse probability weighted discrete-time hazard models with time-updated exposure and covariates to estimate effects of current and long-term caregiving on incident hypertension. We tested for effect modification by race, gender, and recipient memory illness. Sensitivity analyses restricted to respondents whose spouses had care needs. After adjusting for demographic, socioeconomic, and health factors, (including risk behaviors, comorbid conditions, and self-rated health), current caregiving significantly predicted hypertension incidence (risk ratio (RR) = 1.36, 95% confidence interval (CI): 1.01, 1.83). For long-term caregivers, there was significant evidence of risk of hypertension onset associated with caregiving (RR = 2.29, 95% CI: 1.17, 4.49). The risk of hypertension onset associated with both current and long-term caregiving did not vary by race, gender, or recipient memory illness diagnosis. Sensitivity analyses supported the primary findings. Providing IADL care to a spouse significantly predicted hypertension onset in a nationally representative sample of US adults.

Caring for teens with chronic illness

With advances in medicine, more children with chronic illness are reaching adolescence and young adulthood. Research has shown that this group is not immune to the behavioral risks endorsed by healthy adolescents. Recent literature exploring the etiology of risk behaviors and their impact on chronic illness is presented. Risk taking may be the result of differential maturation of two distinct parts of the adolescent brain. Risk taking can be considered normal in adolescents with chronic illness, but there is some evidence that chronic illness affects normal psychosocial development. Moreover, evidence supports that chronic illness can lead to disparities in risk education and assessment because of disease focused management rather than a more comprehensive approach. Youth living with chronic illnesses face unique challenges in accomplishing the developmental tasks of adolescence. These challenges include risk behaviors, which jeopardize current and future health. The reasons for risk taking are multifactorial and require providers to make the adolescent and not the illness the center of management. More research is needed on how to improve developmentally appropriate and relevant interventions to aid in safe passage into adulthood.

Lifetime Sexual Behavior of Psychiatric Inpatients

Sexual life of psychiatric patients, including risk behaviors related to sexually transmitted diseases, remains a poorly studied area, especially in those with severe mental illnesses. To assess some aspects of lifetime sexual behavior of psychiatric inpatients. Patients consecutively admitted to a psychiatric unit in a general hospital were interviewed about partner-related lifetime sexual behavior. A semi-structured interview developed by the authors was used to collect information concerning their general sexual experience throughout life, homosexual and heterosexual relations, and relations with partners who were intravenous drug users (IVDU), HIV carriers or suffering from AIDS, and with sex workers. In each of these areas, time elapsed since last sexual contact; number of partners in previous year, frequency of these relations and condom use were investigated. Five hundred forty-six patients (306 men and 240 women) were assessed, and 87.7% of them reported sexual relations at some point during their life. Of these, 90% reported heterosexual and 10% homosexual or bisexual sexual contacts. Further, 11.06% had had at least one partner who was an IVDU; 8.1% an HIV-positive partner, and 32.4% (50% of the men) had paid for sex. Overall 49.79% of the total sample reported never using condoms in their sexual relations, with similar percentages for those with HIV-positive (46%) and IVDU (47%) partners. Of those who paid for sex, 29% never used condoms. Psychiatric patients admitted to a general hospital psychiatric unit have sexual experience close to the general population, with a higher percentage of homosexual contacts and lower rates of condom use, even in higher risk situations, such as men having sex with men, and partners who are HIV-positive or IVDUs. This information obliges clinicians to systematically explore the sexual behavior of psychiatric patients, evaluate risk behaviors, and adopt measures to promote safe sex practices in this population.

Correlates of Sexual Risk Behaviors Among High School Students in Colorado: Analysis and Implications for School-based HIV/AIDS Programs

Objectives of this study are to examine correlates of antecedent sexual risk exposures associated with HIV/AIDS infection among adolescents participating in the 2005 Colorado Youth Behavioral Risk Survey (CYBRS), and to determine gender differences associated with these exposures since previous studies have produced mixed findings. Variables assessing these relationships were drawn from CYBRS, 2005. We used χ2 to assess bivariate relationships and multinomial logistic regression to evaluate associations among dependent variables (sexual risk behaviors, age at first sex, and number of sexual partners in the past 3 months) and independent variables (in-school HIV/AIDS education, use of illegal substances, physically forced sex, and alcohol use). We found no significant effect of having received in-school HIV/AIDS education on all outcome measures. Compared with females, males were more likely to initiate sex at a relatively younger age, report unprotected sex with multiple partners, and drink alcohol before sexual intercourse. Among females, using 2 illegal substances increased the odds of early sexual debut by 12 times, while using ≥3 substances increased the same odds to 44-fold. Likewise, binge drinking was also associated with higher odds of having multiple partners. Hispanic ethnicity and physically forced sex variables were consistently associated with high risk sexual behaviors, early sexual initiation, and increased number of sexual partners. Efforts to control the HIV/AIDS epidemic among adolescents may need to focus on targeted interventions aimed at addressing gender- and racial/ethnic-specific risk exposures among this population group, including risk behaviors linked with lifetime physically forced sex. The need to re-examine the role of in-school HIV prevention programs to build adequate competencies among students, parents and community leaders to reduce risk exposures associated with HIV/AIDS infection among youth is emphasized.

Development, Risk, and Resilience of Transgender Youth

Transgender youth face unique and complex issues as they confront cultural expectations of gender expression and how these fit with what is natural for them. Striving for balance, learning to cope, questioning, and eventually becoming comfortable with one's gender identity and sexual orientation are of paramount importance for healthy growth and development. Ineffective management of intense challenges over time without adequate social support places youth at risk for a number of unhealthy behaviors, including risk behaviors associated with acquiring HIV. This article explores early foundations of gender identity development, challenges in the development of transgender youth, and the limited data that exist on transgender youth and HIV risks. The concept of resilience is introduced as a counterbalancing area for assessment and intervention in practice and future research with transgender youth.

Adolescents' health beliefs are critical in their intentions to seek physician care

Background The examination of predictors of adolescents' intentions to use health care for different types of health issues has received little attention. This study examined adolescents' health beliefs and how they relate to intentions to seek physician care across different types of health problems. Methods Two hundred ten high school students (54% females; 76.6% participation rate) completed a self-administered survey of four separate age- and gender-specific health case scenarios: an adolescent who has symptoms of pneumonia; smokes five cigarettes daily; plans to initiate sex; and has symptoms of depression. For each health scenario, participants rated the seriousness of the health problem, physician effectiveness, and intentions to seek physician care. Results Most adolescents believed all health problems were serious except for planning to initiate sex ( P < 0.001). Adolescents believed that physicians were most effective in diagnosis and treatment for pneumonia, followed by cigarette use, depression, and sex, respectively ( P's < 0.001). Adolescents' intentions to seek physician care were greatest for physical as compared to risk behavior or mental health problems ( P < 0.001). Multiple regression analyses revealed that adolescents had greater intentions to seek physician care for cigarette, sex, and depression when they believed physicians were effective and they perceived these as health problems after controlling for age and gender (all P's < 0.001). Health beliefs explained 12% to 49% of the variance in intentions to seek care (all P's < 0.001). Conclusions Adolescents' health beliefs are important when understanding intentions to seek physician care. Health care use may be improved by increasing adolescents' beliefs that physicians are effective in areas other than physical health, including risk behaviors and mental health.

HIV surveillance among injecting drug users

Injecting drug users (IDUs) should be considered a 'partially hidden population' at high risk for HIV infection. In almost all locations it should be possible to locate and conduct research with IDUs, but it will probably never be possible to enumerate or draw random samples from an IDU population. Surveillance research studies with IDUs should include risk behaviors, as surveillance of HIV infection only will not be sufficiently time sensitive, and be used to develop and refine HIV prevention programming for the population. Contacts with IDUs can be developed at multiple settings, including voluntary treatment programs, law enforcement settings, and through 'street outreach.' Each type of setting has different advantages, disadvantages and ethical concerns. HIV testing as part of surveillance also raises additional important ethical concerns. The primary risk behaviors that should be included in surveillance studies are 'sharing' of drug injection equipment, the potential for rapid partner change among risk partners, and sexual risk behavior. Additional important objectives for surveillance research include: (1) the size of the local IDU population, (2) patterns of drug use, (3) availability injection equipment, (4) participation in prevention activities, and (5) access to and use of anti-retroviral treatments. HIV incidence is an ultimate objective for surveillance research, but there are no currently available cost-efficient methods for studying HIV incidence, so estimation from indirect measurements is usually required.