Women's Health Issues - Articles in Press

Smoking Among Pregnant Women With Disabilities - Corrected Proof

Monika Mitra, Emily Lu, Hafsatou Diop — 2012-01-24

Abstract: Purpose: The purpose of this study was to examine the prevalence of smoking before, during, and after pregnancy among a representative sample of Massachusetts women with and without disabilities.Methods: Data from the 2007 to 2009 Massachusetts Pregnancy Risk Assessment Monitoring System survey were used to estimate the prevalence of smoking by disability status.Main Findings: Disability prevalence was 4.8% (n = 204) among Massachusetts women giving birth during 2007 through 2009. The prevalence of smoking during the 3 months before pregnancy among women with disabilities was 37.3% (95% CI, 28.3–47.2%) compared with 18.3% (95% CI, 16.6–20.1%) among women without disabilities. Similarly, 25.2% (95% CI, 17.3–35.2%) of women with disabilities, compared with 9.4% of women without disabilities (95% CI, 8.1–10.8%), smoked during the last trimester of their pregnancy, and 32.1% of women with disabilities (95% CI, 23.5–42.1%) compared with 12.5% of women without disabilities (95% CI, 11.1–14.1%), smoked after pregnancy. In the multivariate logistic regression models, women with disabilities had significantly higher risks of smoking before, during and after pregnancy than women without disabilities (adjusted relative risk [aRR], 1.7 [95% CI, 1.2–2.2]; aRR, 1.9 [95% CI, 1.3–2.8]; aRR, 1.8 [95% CI, 1.3–2.5], respectively) while adjusting for race/Hispanic ethnicity, marital status, education, age, household poverty status, and infant’s birth year.Implications: Women with disabilities are more likely to smoke before, during, and after their pregnancy and less likely to quit smoking during pregnancy. Efforts to integrate and target pregnant women with disabilities in smoking-cessation programs are vital.

Urban–Rural Differences in Attitudes and Practices Toward Long-Acting Reversible Contraceptives among Family Planning Providers in Texas - Corrected Proof

Margaret L. Vaaler, Lauri K. Kalanges, Vincent P. Fonseca, Brian C. Castrucci — 2012-01-24

Abstract: Background: Despite the elevated rates of teen and unplanned pregnancies across the United States, long-acting reversible contraceptives (LARCs) remain a less utilized birth control method. The present study investigated family planning providers’ attitudes and considerations when recommending family planning methods and LARCs to clients. Additionally, this study explored whether urban–rural differences exist in providers’ attitudes toward LARCs and in clients’ use of LARCs.Methods: Data were collected using an online survey of family planning providers at Title X clinics in Texas. Survey data was linked to family planning client data from the Family Planning Annual Report (2008).Results: Findings indicated that, although providers were aware of the advantages of LARCs, clients’ LARC use remains infrequent. Providers reported that the benefits of hormone implants include their effectiveness for 3 years and that they are an option for women who cannot take estrogen-based birth control. Providers acknowledged the benefits of several types of LARCs; however, urban providers were more likely to acknowledge the benefits of hormone implants compared with their rural counterparts. Results also indicated barriers to recommending LARCs, such as providers’ misinformation about LARCs and their caution in recommending LARCs to adolescents. However, findings also indicated providers lack training in LARC insertion, specifically among those practicing in rural areas.Conclusions: In light of the effectiveness and longevity of LARCs, teenagers and clients living in rural areas are ideal LARC candidates. Increased training among family planning providers, especially for those practicing in rural areas, may increase their recommendations of LARCs to clients.

Multilevel Analysis of the Determinants of Receipt of Clinical Preventive Services Among Reproductive-Age Women - Corrected Proof

2012-01-24

Abstract: Background: We investigated the impact of individual- and county-level contextual variables on women’s receipt of a comprehensive panel of preventive services in a region that includes both urban and rural communities.Methods: Outcome variables were a screening and vaccination index (a count of Papanicolaou test, blood pressure check, lipid panel, sexually transmitted infections [STI] or HIV test, and influenza vaccination received in the past 2 years) and a preventivecounseling index (a count of topics discussed in the past 2 years: Smoking and tobacco, alcohol or drugs, violence and safety, pregnancy planning or contraception, diet/nutrition, and STIs). Contextual covariates from the Area Resource File (2004–2005) were appended to prospective survey data from the Central Pennsylvania Women’s Health Study. Individual-level variables included predisposing, enabling, and need-based measures. Contextual variables included community characteristics and healthcare resources, including a measure of primary care physician (PCP) density specifically designed for this study of women’s preventive care. Multilevel analyses were performed.Results: We found low overall use of preventive services. In multilevel models, individual-level factors predicted receipt of both screening and vaccinations and counseling services; significant predictors differed for each index. One contextual variable (PCP density) predicted receipt of screenings and vaccinations.Conclusions: Women’s receipt of preventive services was determined primarily by individual-level variables. Different variables predicted receipt of screening and vaccination versus counseling services. A contextual measure, PCP density, predicted receipt of preventive screenings and vaccinations. Individual variability in women’s receipt of counseling services is largely explained by psychosocial factors and seeing an obstetrician-gynecologist.

Transactional Sexual Relationships, Sexually Transmitted Infection Risk, and Condom Use Among Young Black Women in Peri-Urban Areas of the Western Cape Province of South Africa - Corrected Proof

2012-01-24

Abstract: Background: Transactional sexual behavior has been demonstrated as an important factor underlying the HIV epidemic in sub-Saharan Africa. The aim of this study was to evaluate the relationship between having a history of transactional sexual relationships with condom use and STI risk.Methods: Participants completed a behavioral questionnaire in isiXhosa and provided self-collected vaginal swabs which were tested for Chlamydia trachomatis, Neisseria gonorrhea, and Trichomonas vaginalis. Multinomial logistic regression was used to compare condom use rates and sexually transmitted infection (STI) risk among women with a history of transactional sexual relationships to women with a history of casual sexual relationships and those with no history of casual sexual relationships.Results: Of the 446 respondents, 223 (50%) reported no history of casual sexual relationships, 94 (23.32%) indicated a history of casual sexual relationships, and among these 119 (26.68%) reported a history of transactional sexual relationships with casual partners. Participants with a history of transactional sexual relationships had a higher rate of condom use with a main partner and a lower prevalence of Chlamydia infection than participants with a history of casual relationships. Participants with a history of transactional sexual relationships were also less likely to have had a STI in the past compared with those who indicated no history of casual relationships.Conclusion: These results highlight attempts by women who report participation in transactional sex to use condoms. The results also point to possibly concealed risk to STI and HIV among women who indicate no history of transactional sex.

Identifying Risk Factors for Disparities in Breast Cancer Mortality among African-American and Hispanic Women - Corrected Proof

Nancy Tian, Pierre Goovaerts, F. Benjamin Zhan, T. Edwin Chow, J. Gaines Wilson — 2012-01-24

Abstract: Background: This study evaluated the risk factors associated with racial disparities in female breast cancer mortality for African-American and Hispanic women at the census tract level in Texas from 1995 to 2005.Methods: Data on female breast cancer cases were obtained from the Texas Cancer Registry. Socioeconomic and demographic data were collected from Census 2000. Network distance and driving times to mammography facilities were estimated using Geographic Information System techniques. Demographic, poverty and spatial accessibility factors were constructed using principal component analysis. Logistic regression models were developed to predict the census tracts with significant racial disparities in breast cancer mortality based on racial disparities in late-stage diagnosis and structured factors from the principal component analysis.Results: Late-stage diagnosis, poverty factors, and demographic factors were found to be significant predictors of a census tract showing significant racial disparities in breast cancer mortality. Census tracts with higher poverty status were more likely to display significant racial disparities in breast cancer mortality for both African Americans (odds ratio [OR], 2.43; 95% confidence interval [CI], 1.95–3.04) and Hispanics (OR, 5.30; 95% CI, 4.26–6.59). Spatial accessibility was not a consistent predictor of racial disparities in breast cancer mortality for African-American and Hispanic women.Conclusion: Physical access to mammography facilities does not necessarily reflect a greater utilization of mammogram screening, possibly owing to financial constraints. Therefore, a metric measuring access to health care facilities is needed to capture all aspects of access to preventive care. Despite easier physical access to mammography facilities in metropolitan areas, great resources and efforts should also be devoted to these areas where racial disparities in breast cancer mortality are often found.

A Qualitative Study Examining the Perceived Barriers and Facilitators to Medical Healthcare Services among Women with a Serious Mental Illness - Corrected Proof

2011-12-16

Abstract: Objective: This qualitative study investigates the barriers and facilitators to accessing and utilizing healthcare services among women with a serious mental illness (SMI).Methods: A purposive sample of 30 poor, urban, predominantly African-American women with a diagnosis of an SMI was recruited. Interviews were audio-taped and transcribed verbatim. Data analysis was guided by a modified constant comparison approach.Results: The findings highlight a variety of nonmedical factors that serve as both barriers and facilitators to accessing and utilizing medical healthcare services, such as a trusting relationship with a mental health provider and a women’s social network.Conclusion: Nonmedical factors and personal circumstances seem to be important factors influencing pathways to healthcare services among women with an SMI. Efforts to better engage and retain women with an SMI into healthcare will need to better acknowledge and incorporate the larger social context of the women’s lives.

Emergency Department Care of Female Veterans - Corrected Proof

Nancy Lutwak — 2011-12-16

To the Editors: I have been an emergency medicine physician for over 20 years and have the pleasure of working in the Department of Emergency Medicine at VA New York Harbor Healthcare System in Manhattan. The recent Women’s Health Issues Supplement (Volume 21, Issue 4S), which featured numerous articles reflecting past and ongoing health research dealing with female veterans, was truly inspiring. Because women have become the fastest growing group of veterans who are new users of the VA health care system, not only do we need to continue such valuable research, but we must accommodate women’s needs. We are committed to providing female veterans with gender sensitive care in private and comfortable areas in the hospital. Women’s clinics have been implemented with women providers.

Physical Activity and Nutrition among Immigrant and Refugee Women: A Community-Based Participatory Research Approach - Corrected Proof

2011-12-12

Abstract: Background: Immigrant and refugee populations arrive to the U.S. healthier than the general population, but the longer they reside, the more they approximate the cardiovascular risk profiles of the country. Among women, these declines are partly mediated by less physical activity and lower dietary quality upon immigration. Given the complex forces that influence these behaviors, a community-based participatory research (CBPR) approach is appropriate. Therefore, a socioculturally responsive physical activity and nutrition program was created with and for immigrant and refugee women in Rochester, Minnesota, through a CBPR approach.Methods: Focus groups informed program content and revealed principles for designing the sessions. A 6-week program with two, 90-minute classes per week was conducted among 45 women (Hispanic, Somali, Cambodian, and non-immigrant African American). Average attendance was 22.5 women per class; 34 women completed the evaluation.Results: Evaluation revealed high acceptability (average overall score of 4.85 out of 5 on the Physical Activity Class Satisfaction Questionnaire). After the intervention, participants were more likely to exercise regularly (p ≤ .001). They reported higher health-related quality of life (p ≤ .001) and self-efficacy for diet (p = .36) and exercise (p = .10). Likewise, there were trends for weight loss (87 vs 83.4 kg; p = .65), decreased waist circumference (99.6 vs 95.5 cm; p = .35), and lower blood pressure (125/80 vs 122/76 mm/Hg; p = .27).Conclusion: A CBPR approach to design and implement a socioculturally responsive fitness program was highly acceptable to immigrant and refugee women and demonstrated promising outcomes. Further testing of physical activity and nutrition interventions that arise organically from target communities are needed.

A Mystery Caller Evaluation of Medicaid Staff Responses about State Coverage of Abortion Care - Corrected Proof

Amanda Dennis, Kelly Blanchard — 2011-12-12

Abstract: Objectives: The Hyde Amendment prohibits federal Medicaid funding for abortion except when a woman is seeking an abortion for a pregnancy that is the result of rape or incest, or that threatens her life. We investigated how Medicaid staff in 17 states responded to inquiries about coverage for abortion in the few circumstances that qualify for federal Medicaid funding.Methods: Using a mystery caller approach, we surveyed Medicaid staff about the availability of abortion coverage, the process for obtaining coverage, and the associated costs for an abortion in circumstances of rape and life endangerment in five states where Medicaid coverage should be available to cover most abortions and in 12 states with restrictions on the circumstances under which Medicaid funding can be used for abortion.Findings: We were able to complete 82% of surveys. Medicaid staff definitively provided information about the availability of coverage that was consistent with state policies in 64% of surveys. However, 52% of staff reported that coverage could be difficult to obtain and that rigorous documentation of the circumstances of the abortion was required. Information about copays for abortion was given in 78% of surveys. We subjectively rated the caller’s experience with Medicaid staff as excellent during 32% of the surveys, adequate in 61% of surveys, and poor in 7% of surveys.Conclusion: Medicaid staff provided inconsistent information that was often discouraging of women seeking abortion coverage, suggesting that women may have difficulties obtaining accurate information about Medicaid coverage of abortion, which may deter access to care.

Decomposing Gender Differences in Low-Density Lipoprotein Cholesterol Among Veterans With or at Risk for Cardiovascular Illness - Corrected Proof

Usha Sambamoorthi, Sophie Mitra, Patricia A. Findley, Leonard M. Pogach — 2011-12-02

Abstract: Objectives: To measure the extent to which gender differences in poor lipid control among individuals at risk for cardiovascular diseases could be explained by patient-level characteristics.Study Design: Cross-sectional analyses of merged Veteran Health Administration (VHA) and Medicare claims data for the fiscal years (FY) 2002 and 2003 consisting of veterans using VHA facilities and were diagnosed with diabetes or heart disease or hypertension during FY 2002 and had recorded LDL cholesterol values in FY2003 (N = 527,568). There were 10,582 women and 516,986 men veterans. Poor lipid control was defined as LDL cholesterol values ≥130 mg/dL. Multivariate techniques consisted of logistic regressions. Based on the parameter estimates and distribution of individual characteristics, we used a decomposition technique to analyze factors that contributed to the gender difference in poor lipid control.Principal Findings: A significantly higher percent of women (27.4%) than men (17.1%) had LDL cholesterol values ≥130 mg/dL. Of the 10.3 percentage point difference in lipid control, 3.4 percentage points were explained by variables included in the model. The gender difference in poor lipid control was mostly explained by age, physical illnesses, use of lipid lowering medications and depression.Conclusions: Only one-third of the gender difference in poor lipid control could be explained by differences in individual characteristics, some of which are modifiable or could be used to identify groups at risk with poor lipid control. Our findings suggest that gender differences in lipid control could be partially reduced by increasing the prescription of lipid lowering drugs and treating depression among women. Interventions that improve lipid control in the non-elderly will also benefit women. However the largest part of the difference in lipid control between women and men remains unexplained and further research is needed to identify additional modifiable and unmodifiable factors.

It’s the Amount of Thought that Counts: When Ambivalence Contributes to Mammography Screening Delay - Corrected Proof

2011-11-04

Abstract: Purpose: This study examines whether ambivalence toward mammography screening, as moderated by total amount of thought given to the reasons for and against getting mammograms at recommended intervals, predicts greater delay in obtaining subsequent screening mammograms.Methods: A sample of 3,430 insured women with recent (within the last 8–9 months) screening mammograms completed telephone interviews as part of a 5-year intervention study to achieve sustained adherence to annual-interval mammography. Delay was assessed by the number of days between mammograms.Results: Controlling for demographic factors and perceived screening barriers, days between mammograms increased as ambivalence and thought increased. Thought moderated ambivalence: Among women who were most ambivalent, women obtained mammograms 1 month earlier for each unit increase in thought.Conclusion: Future studies should test innovative ways to resolve ambivalence and increase thought about consequences of getting mammograms as a strategy to promote mammography screening adherence.

Organizational Factors Associated with Screening for Military Sexual Trauma - Corrected Proof

2011-11-04

Abstract: Purpose: This exploratory study investigated organizational factors associated with receipt of military sexual trauma (MST) screening during an early timeframe of the Veterans Health Administration’s (VHA) implementation of the universal MST screening policy.Methods: The sample consisted of all VHA patients eligible for MST screening in fiscal year 2005 at 119 VHA facilities. Analyses were conducted separately by gender and by user status (i.e., new patients to the VHA health care system in FY 2005 and continuing users who had previously used the VHA health care system in the past year). Multivariate generalized estimating equations were used to assess the effects of facility-level characteristics and adjusted for person-level covariates.Results: Facility-level mandatory universal MST screening policies were associated with increased odds of receiving MST screening among new female patients and both continuing and new male patients: Odds ratio (OR), 2.87 (95% confidence interval [CI], 1.39–5.89) for new female patients; OR, 8.15 (95% CI, 2.93–22.69) for continuing male patients; and OR, 4.48 (95% CI, 1.79–11.20) for new male patients. Facility-level audit and feedback practices was associated with increased odds of receiving MST screening among new patients: OR, 1.91 (95% CI, 1.26–2.91) for females and OR, 1.86 (95% CI, 1.22–2.84) for males. Although the facility-level effect for women’s health clinic (WHC) did not emerge as significant, patient-level effects indicated that among these facilities, women who used a WHC had greater odds of being screened for MST compared with women who had not used a WHC: OR, 1.79 (95% CI, 1.18–2.71) for continuing patients and OR, 2.20 (95% CI, 1.59–3.04) for new patients.Conclusion: This study showed that facility policies that promote universal MST screening, as well as audit and feedback practices at the facility, significantly improved the odds of patients receiving MST screening. Women veterans’ utilization of a WHC was associated with higher odds of receiving MST screening. This study provides empirical support for the use of policies and audit and feedback practices which the VHA has used since the implementation of the MST screening directive to encourage compliance with VHA’s MST screening policy and is likely associated with the present-day success in MST screening across all VHA facilities.

Raising the Bar for Breast Health Care in the United States - Corrected Proof

Meena S. Moran, M. Tish Knobf — 2011-10-31

Annually, nearly 39 million women undergo mammography in the United States (), approximately 200,000 women are diagnosed with breast cancer, and 40,000 women die of the disease (). As such, breast health remains a critical area focus not only for clinicians, but also for health care policy analysts, researchers, and payers. There has been a recent evolution to standardize the delivery of breast health care (BHC) across the nation, with defined guidelines, quality indicators (QI), and expectations for treating physicians. Why is the dissemination of this information important? As these initiatives in BHC gain acceptance and provide standards for practice and benchmarks for QI, the value of breast physician-specialists and breast programs meeting national standards and striving to deliver quality care will be realized, with the hope that participants in these initiatives will be identified (and distinguished) for their continued participation in these national “validation” processes, and ultimately, will improve upon the multidisciplinary care/outcomes for breast cancer.

Risk Factors for Intimate Partner Violence Initiation and Persistence Among High Psychosocial Risk Asian and Pacific Islander Women in Intact Relationships - Corrected Proof

2011-10-17

Abstract: Purpose: The present study identifies risk factors for intimate partner violence (IPV) initiation and persistence over three years in a high psychosocial risk Asian American and Pacific Islander (AAPI) sample of women with children living in Hawaii.Methods: We included 378 women in a 3-year relationship with the same partner who reported IPV experiences at baseline and 3 years later. Baseline risk factors included characteristics of each woman, her partner, and their relationship. Bivariate and multivariate regression models were conducted to assess the influence of risk factors on the likelihood of experiencing IPV initiation and persistence.Findings: Of women who experienced no physical violence at baseline, 43% reported IPV initiation. Of women who did experience physical violence at baseline, 57% reported IPV persistence. Being unemployed and reporting poor mental health at baseline are important risk factors for experiencing IPV initiation. Reporting frequent physical violence at baseline increases the likelihood of experiencing IPV persistence. Asian women were significantly less likely to report IPV persistence than other groups of women.Conclusions: Our study indicates that among a high psychosocial risk sample of AAPI women there are different risk factors for IPV initiation and persistence. Future prevention and screening efforts may need to focus on these risk factors.

Attitudes Toward Unprotected Intercourse and Risk of Pregnancy Among Women Seeking Abortion - Corrected Proof

2011-10-17

Abstract: Background: Despite the high prevalence of unintended pregnancies caused by lack of contraceptive use, little is known about women’s reasons for or attitudes toward unprotected intercourse (UI).Methods: We included 562 women seeking pregnancy termination at six U.S. abortion clinics who completed surveys on their experiences and attitudes about UI, knowledge of the risk of conception, and willingness to engage in UI in the future.Results: Respondents reported an average of 18 acts of UI leading up to conception. The most commonly reported reasons for UI were thinking one could not get pregnant (42%), difficulties procuring a contraceptive method (40%), and not planning to have sex (38%). When asked about attitudes toward UI, 48% reported that UI feels better or more natural, 36% said it is okay to have UI once in a while or at certain times of the month, and 28% cited partner or relationship benefits as a reason to engage in UI. In addition, 23% said they were somewhat or extremely likely to engage in UI in the next 3 months. Younger women (<20 years), women who named partner or relationship benefits to UI, and women who underestimated the risk of conception were significantly more willing to engage in UI in the next 3 months.Conclusions: Given the prevalence of risk taking and the perceived benefits of UI, contraceptives, particularly long-acting methods, need to be made easy to procure and use. The success of coital specific methods may be limited by women underestimating the risk of conception.

Reproductive Health Care Utilization Among Young Mothers in Bangladesh: Does Autonomy Matter? - Corrected Proof

Syed Emdadul Haque, Mosiur Rahman, Md. Golam Mostofa, Md. Sarwar Zahan — 2011-10-04

Abstract: Objective: To examine the linkage between the possible influences of the extent of autonomy on young mothers use of reproductive health care services.Methods: This paper used data from the 2007 Bangladesh Demographic Health Survey. The analyses were based on responses of 1,778 currently married women aged 15 to 24 years, living with at least one 0- to 35-month-old child. Utilization of antenatal health services (ANC) services by amount and type of provider, and utilization of delivery assistance according to provider type were used as proxy outcome variables of reproductive health care utilization. Descriptive statistics and multivariate logistic regression methods were employed in the analysis.Results: Approximately one third (31%) of the currently married young women in Bangladesh had a higher level of overall decision-making autonomy. Only 24.0% of the sampled women received sufficient ANC; 54% and 18% received ANC and assisted deliveries from a medically trained provider. respectively. In adjusted models, young women who had a higher level of overall autonomy were more likely to receive sufficient ANC (adjusted odds ratio [AOR], 1.64; 95% confidence interval [CI], 1.17–2.23) and receiving ANC from medically trained provider (AOR, 1.91; 95% CI, 1.42–2.45). Women who had medium overall autonomy were 1.40 times more likely (95% CI, 1.03–1.98) to have deliveries assisted by a medically trained provider than women who had low autonomy.Conclusion: Association between young mother’s autonomy and reproductive health care utilization suggest that maternal autonomy needs to be considered as an important sociocultural determinant for the higher utilization of reproductive health care services for young mothers in Bangladesh.

Postpartum Screening for Diabetes Among Medicaid-Eligible South Carolina Women With Gestational Diabetes - Corrected Proof

2011-10-03

Abstract: Purpose: To examine the rate of timely postpartum screening for diabetes among Medicaid-eligible women with gestational diabetes mellitus (GDM).Methods: We examined a retrospective cohort of Medicaid women with a live birth between 2004 and 2007. Women with singleton live births at greater than 28 weeks gestation were included in the cohort and their screening receipt tracked. Only the first qualifying pregnancy within the observation period was assessed. Birth certificate records were linked with hospital discharge data, outpatient prenatal care claims to identify women with GDM (n = 6,239). Medicaid postpartum claims for these women were examined to determine receipt of postpartum screening for diabetes within 5 to 13 weeks. Women with any indication of a dedicated plasma glucose test identified by CPT codes 82947, 82950, 82951, and 82952 during this time period were considered to meet the definition of screening.Results: Approximately 3.4% of women identified as having GDM were screened for diabetes postpartum. Adjusted analysis found women not attending the postpartum visit (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.37–0.91) and women receiving inadequate prenatal care (OR, 0.57; 95% CI, 0.34–0.95) were less likely to receive postpartum screening for diabetes. Conversely, women 20 to 34 years of age (OR, 1.79; 95% CI, 1.21–2.66) and women who were obese (OR, 2.28; 95% CI, 1.56–3.32) were more likely to be screened.Conclusions: Medicaid is a primary source of insurance for many women; however, for most coverage ends at 60 days postpartum, leaving a narrow window of opportunity for postpartum screening. Extended periods of coverage may be beneficial in ensuring the opportunity to receive adequate postpartum care, including screening for diabetes.