Women In Counties Research Articles

The impact of Medicaid managed care on pregnant women in Ohio: a cohort analysis.

To examine the impact of mandatory HMO enrollment for Medicaid-covered pregnant women on prenatal care use, smoking, Cesarean section (C-section) use, and birth weight. Linked birth certificate and Medicaid enrollment data from July 1993 to June 1998 in 10 Ohio counties, 6 that implemented mandatory HMO enrollment, and 4 with low levels of voluntary enrollment (under 15 percent). Cuyahoga County (Cleveland) is analyzed separately; the other mandatory counties and the voluntary counties are grouped for analysis, due to small sample sizes. Study Design. Women serve as their own controls, which helps to overcome the bias from unmeasured variables such as health beliefs and behavior. Changes in key outcomes between the first and second birth are compared between women who reside in mandatory HMO enrollment counties and those in voluntary enrollment counties. County of residence is the primary indicator of managed care status, since, in Ohio, women are allowed to "opt out" of HMO enrollment in mandatory counties in certain circumstances, leading to selection. As a secondary analysis, we compare women according to their HMO enrollment status at the first and second birth. Linked birth certificate/enrollment data were used to identify 4,917 women with two deliveries covered by Medicaid, one prior to the implementation of mandatory HMO enrollment (mid-1996) and one following implementation. Data for individual births were linked over time using a scrambled maternal Medicaid identification number. The effects of HMO enrollment on prenatal care use and smoking were confined to Cuyahoga County, Ohio's largest county. In Cuyahoga, the implementation of mandatory enrollment was related to a significant deterioration in the timing of initiation of care, but an improvement in the number of prenatal visits. In that county also, women who smoked in their first pregnancy were less likely to smoke during the second pregnancy, compared to women in voluntary counties. Women residing in all the mandatory counties were less likely to have a repeat C-section. There were no effects on infant birth weight. The effects of women's own managed care status were inconsistent depending on the outcome examined; an interpretation of these results is hampered by selection issues. Changes over time in outcomes, both positive and negative, were more pronounced for African American women. With careful implementation and attention to women's individual differences as in Ohio, outcomes for pregnant women may improve with Medicaid managed care implementation. Quality monitoring should continue as Medicaid managed care becomes more widespread. More research is needed to identify the types of health maintenance organization activities that lead to improved outcomes.

Vietnamese American Women's Health: A Community's Perspective and Report

This article discusses findings from focus groups conducted in the Vietnamese American community as part of a needs assessment to better understand the issues of breast and cervical cancer screening for Asian American and Pacific Islander (AAPI) women in Los Angeles and Orange Counties. First, we present an overview of community sociodemographics and the problems of breast and cervical cancer for Vietnamese American women. Then we give a brief background of the REACH 2010 Initiative and the Promoting Access to Health for Pacific Islander and Southeast Asian Women (PATH for Women) project, which is a community collaborative program to reduce barriers to cancer prevention in seven AAPI communities. We then discuss Vietnamese American women in the context of their own community culture.

Breast, cervical, and colorectal carcinoma screening in a demographically defined region of the southern U.S.

The "Southern Black Belt," a term used for > 100 years to describe a subregion of the southern U.S., includes counties with high concentrations of African Americans and high levels of poverty and unemployment, and relatively high rates of preventable cancers. The authors analyzed data from a state-based telephone survey of adults age >or= 18 years to compare the cancer screening patterns of African-American and white men and women in nonmetropolitan counties of this region, and to compare those rates with those of persons in other southern counties and elsewhere in the U.S. The primary study groups were comprised of 2165-5888 women and 1198 men in this region interviewed through the Behavioral Risk Factor Surveillance System. The respondents lived in predominantly rural counties in 11 southern states with sizeable African-American populations (>or= 24.5% of county residents). The main outcome measures were recent use of the Papanicolau (Pap) test, mammography, test for fecal occult blood in the stool (FOBT), and flexible sigmoidoscopy or colonoscopy. Between 1998-2000, 66.3% (95% confidence interval [95% CI] +/- 2.7%) of 1817 African-American women in the region age >or= 40 years had received a mammogram within the past 2 years, compared with 69.3% (95% CI +/- 1.8%) of 3922 white women (P = 0.066). The proportion of African-American and white women who had received a Pap test within the past 3 years was similar (85.7% [95% CI +/- 1.9%] vs. 83.4% [95% CI +/- 1.5%]; P = 0.068]. In 1997 and 1999, 29.3% of African-American women in these counties reported ever receiving an FOBT, compared with 36.9% in non-Black Belt counties and 42.5% in the remainder of the U.S. Among white women, 37.7% in Black Belt counties, 44.0% in non-Black Belt counties, and 45.3% in the remainder of the U.S. ever received an FOBT. Overall, similar patterns were noted among both men and women with regard to ever-use of FOBT, flexible sigmoidoscopy, or colonoscopy. Screening rates appeared to vary less by race than by region. The results of the current study underscore the need for continued efforts to ensure that adults in the nonmetropolitan South receive educational messages, outreach, and provider recommendations concerning the importance of routine cancer screening.

Family Planning Clinic Services in the United States: Patterns and Trends in the Late 1990s

Publicly funded family planning clinics are a vital source of contraceptive and reproductive health care for millions of U.S. women. It is important periodically to assess the number and type of clinics and the number of contraceptive clients they serve. Service data were requested for agencies and clinics providing publicly funded family planning services in the United States in 1997. The numbers of agencies, clinics and female contraceptive clients were tabulated according to various characteristics and were compared with similar data for 1994. Finally, county data were tabulated according to the presence of family planning clinics and private physicians likely to provide family planning care and according to the number of female contraceptive clients served compared with the number of women needing publicly funded care. In 1997, 3,117 agencies offered publicly funded contraceptive services at 7,206 clinic sites. Forty percent of clinics were run by health departments, 21% by community health centers, 13% by Planned Parenthood affiliates and 26% by hospitals or other agencies. Overall, 59% of clinics received Title X funding. Agencies operated an average of 2.3 clinics, and clinics served an average of 910 contraceptive clients per year. Altogether, clinics provided contraceptive services to 6.6 million women-approximately two of every five women estimated to need publicly funded contraceptive care. The total number of providers and the total number of women served remained stable between 1994 and 1997; at the local level, however, clinic turnover was high. Some 85% of all US counties had one or more publicly funded family planning clinics; 36% had one or more clinics, but no private obstetrician-gynecologist. Publicly funded family planning clinics are distributed widely throughout the United States and continue to provide contraceptive care to millions of US women. Clinics are sometimes the only source of specialized family planning care available to women in rural counties. However, the high rate of clinic tumover and the lack of significant growth in clinic numbers suggest that limited funding and rising costs have hindered the further expansion and outreach of the clinic network to new geographic areas and hard-to-reach populations.

Provider Availability, Race, and Abortion Demand

Variations in the availability of abortion providers may impact the demand for abortions since greater provider availability reduces the travel cost associated with obtaining an abortion. This paper applies a fertility-control model to estimate the responsiveness of abortion demand to travel-cost variations using individual data from all births and abortions of women over age 20 in the state of Texas for 1993. The probability that a pregnant woman chooses an abortion appears to be sensitive to availability-induced variations in the travel cost of abortion services. Controlling for the endogeneity of travel distance, the results suggest that pregnant women who reside in counties with longer travel distances to the nearest abortion provider have lower probabilities of aborting their pregnancies than women in counties closer to abortion providers. Simulations show that changes in travel distance will have relatively large impacts on overall abortion rates and, furthermore, that these effects vary across race. In addition, these simulations show substantial differences by race in the effects of changes in other explanatory variables.

Provider Availability, Race, and Abortion Demand

Variations in the availability of abortion providers may impact the demand for abortions since greater provider availability reduces the travel cost associated with obtaining an abortion. This paper applies a fertility‐control model to estimate the responsiveness of abortion demand to travel‐cost variations using individual data from all births and abortions of women over age 20 in the state of Texas for 1993. The probability that a pregnant woman chooses an abortion appears to be sensitive to availability‐induced variations in the travel cost of abortion services. Controlling for the endogeneity of travel distance, the results suggest that pregnant women who reside in counties with longer travel distances to the nearest abortion provider have lower probabilities of aborting their pregnancies than women in counties closer to abortion providers. Simulations show that changes in travel distance will have relatively large impacts on overall abortion rates and, furthermore, that these effects vary across race. In addition, these simulations show substantial differences by race in the effects of changes in other explanatory variables.

Effect of a Media-Led Education Campaign on Breast and Cervical Cancer Screening among Vietnamese-American Women

Background.Previous research has shown that breast and cervical cancer screening rates are low among Vietnamese women.Methods.Over a 24-month period, we implemented a media-led community education campaign to promote recognition, intention, receipt, and currency of routine checkups, clinical breast examinations, mammograms, and Pap tests among Vietnamese-American women in Alameda and Santa Clara Counties in northern California. Women in Los Angeles and Orange Counties in southern California served as controls. To evaluate its impact, pretest telephone interviews were conducted of 451 randomly selected women in the intervention area and 482 women in the control area and posttest interviews with 454 and 422 women, respectively.Results.At posttest, after controlling for demographic differences in the surveyed populations, the odds ratios for the intervention effect were statistically significant for having heard of a general checkup, Paptest, and clinical breast examination (CBE); planning to have a checkup, Pap test, CBE, and mammogram; and having had a checkup and Pap test. The intervention had no effect on being up to date for any of the tests.Conclusions.A media-led education intervention succeeded in increasing recognition of and intention to undertake screening tests more than receipt of or currency with the tests.

Factors determining the rate of referral, transplantation, and survival on dialysis in women with ESRD

The determinants of referral for transplantation in women have not been well-studied. Similarly, factors determining survival on dialysis and the rate of transplantation in women remain controversial. Women have been reported to have lower rates of transplantation than men, and black women have the lowest rates of all groups. We questioned whether black women were referred at lower rates than whites and if race and other socioeconomic factors predicted referral, rate of renal transplantation, and patient survival on dialysis. All women in Allegheny or Philadelphia counties in Pennsylvania initiating dialysis between January 1, 1990, and December 31, 1992, were eligible for this study. Information was requested by questionnaire from each dialysis unit in these areas. Of the 383 eligible patients, completed questionnaires were obtained for 276 (72%). Ninety-three (54.7%) of the black patients and 57 (53.8%) of the white patients were referred for transplantation ( P = 0.8). Declining the transplant option was the most common reason for nonreferral in both races. Patients with high school or greater education were approximately twice as likely to be referred than those with grade school educations (odds ratio [OR], 2.2; P = 0.04). Patients with coexisting illness were 67% (OR, 0.33; P = 0.004) less likely to be referred compared with patients with no other illnesses. Each additional year of age reduced the chances of being referred by 6% (OR, 0.94; P = 0.0001). Homemakers were 83% ( P = 0.0008) and others 55% ( P = 0.07) less likely to be referred compared with employed patients. Patients in Philadelphia County were 56% less likely to be referred compared with those in Allegheny County ( P = 0.024). Race was not significantly associated with referral. Predictors of transplantation included age (RR, 0.96; confidence interval [CI], 0.93 to 0.99; P = 0.13), white race (RR, 2.2; Cl, 1.3 to 4.0; P = 0.0053), presence of other illnesses (RR, 0.37; Cl, 0.21 to 0.65; P = 0.0006), and employment status. White homemakers were 86% (RR, 0.14; CI, 0.03 to 0.6; P = 0.0082) less likely than those with other employment situations to receive a transplant. Factors predicting patient survival on dialysis included race, educational status, and presence of comorbid illnesses. White patients were approximately four times (RR, 3.7; CI, 1.7 to 8.1; P = 0.002) more likely to die than black patients. Patients with high school or greater education were 56% (RR, 0.44; CI, 0.2 to 0.92' P = 0.008) less likely to die than those with grade school education alone. Patients with at least one coexisting illness were approximately 1.7 times (RR, 1.68; CI, 1.1 to 2.4; P = 0.001) more likely to die than those without other illnesses. In summary, race was not a factor in referral for transplantation, but was predictive of transplantation and patient survival on dialysis. Socioeconomic factors such as educational status, age, and employment status were highly predictive of transplantation and long-term survival on hemodialysis. White homemakers unexpectedly received transplants less than any other group of dialysis patients. Further study is needed to determine why these potential transplant patients have declined or deferred transplantation.

Progression to Second Birth in China: A Study of Four Rural Counties

This study determines the hazard ratios for determining second births in four rural counties in Hebei and Shandong provinces in China during 1992-93. The sample included 7946 women aged under 35 years in their first marriage who gave birth after 1980. 54% of first births were males. 20% had a second birth (49% in Huasheng county). The second birth sex ratio was 1.41 compared to 1.17 for first births. 34% of women with a first birth in Pangxie county had an abortion while <25% of women in the other counties had abortions. 29.4% of women in Huasheng had a son 4 years after their first birth compared to <4.1% in the other counties. Within 10 years of the first birth 88% of women in Huasheng had a son at their second birth and 69% had a daughter. Only Pangxie had a normal sex ratio. Women with at least a senior high school education were quicker to have more sons. Second births occurred more frequently among women whose first birth was a daughter. The hazard of a second birth was 2.4 times that for a woman with one son. The hazard of a male second birth was 2.8 times that for a woman with a son and 2.1 times for a female second birth. Women in the oldest age group were 40% more likely to have a second birth. Higher economic status reduced the hazard of a second birth. The hazard of a second birth was 14% higher among couples with husbands making major decisions compared to joint decision making. Hazards were higher for first births during 1980-83 1984-86 and 1987-88. Models with county of residence included showed a reduced impact of education. Second births were more common in Huasheng due to the permission granted to wealthy and educated couples to have a second child as long as the fine was paid. These couples learned that fines supported family planning personnel who were willing to monitor more closely poorer and less educated couples who could not pay fines.

Fat, Energy and Breast Cancer

Rates of breast cancer vary approximately fivefold among countries and are strongly correlated with national per capita availability of dietary fat. However, this relation may be substantially confounded by many other factors associated with affluent lifestyles, such as reduced parity and physical activity. In large prospective epidemiologic studies, little evidence has been seen to support any major positive association between dietary fat and risk of breast cancer over the range of 15–45% or more of energy from fat. The observation that women in counties in China consuming approximately 25% of energy from fat have much lower rates of breast cancer than U.S. women with similar fat intakes provides additional evidence that factors other than dietary fat account for the large international differences. Some epidemiologic evidence suggests that monounsaturated fat and olive oil in particular may reduce risk of breast cancer when substituted for other types of fat. In contrast to findings for dietary total fat, most types of epidemiologic studies provide indirect support for a protective effect of energy restriction and reduced growth rates against breast cancer, which is consistently observed in animal studies of mammary carcinogenesis.

Illicit drug use by pregnant women in metropolitan, medium sized, and rural counties using meconium sampling

Illicit drug use by pregnant women in metropolitan, medium sized, and rural counties using meconium sampling

Cardiovascular risk factor changes in the Kilkenny Health Project

The Kilkenny Health Project was a community research and demonstration programme which aimed to reduce risk of cardiovascular disease in a county in the south-east of Ireland with a total population of approximately 70,000. The health promotion programme was carried out in Kilkenny from 1985 to 1992. Outcome evaluation was by means of population surveys of independent samples of men and women aged 35 to 64 years in Kilkenny (n approximately 800) and in the reference county (n approximately 600) in 1985/1986 and in 1990/1991. Survey methods for health behaviour questionnaires and risk factor measurements were similar to those of the WHO MONICA Project. Mean systolic blood pressure (SBP) declined significantly (P < 0.01) in men and women in both counties, from 144.0 by 5.4 mmHg and from 143.2 by 5.4 mmHg in men and from 139.5 by 7.7 mmHg and from 136.5 by 6.6 mmHg in women in the intervention and reference counties. The prevalence of hypertension declined from 23.1% by 2.8% and from 26.1% by 6.0% in men in the two counties. Prevalence declined from 24.1% by 6.2% (P < 0.05) in women in the intervention county but was unchanged, increasing by 0.5% from 17.5%, in women in the reference county. Mean serum total cholesterol declined from 6.04 mmol.l-1 by 0.09 mmol.l-1 and from 6.00 by 0.44 mmol.l-1 (P < 0.01) in men and from 6.01 by 0.36 (P < 0.01) and from 5.90 by 0.31 (P < 0.01) in women in the intervention and reference counties, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Temporal trends in the socioeconomic gradient for breast cancer mortality among US women.

Temporal trends in breast cancer mortality among US women were examined for 1969 through 1989 by age, race, and county-level socioeconomic status (SES). The mortality ratio for high- relative to low-SES counties declined significantly among women 25 to 44, 45 to 64, and more than 65 years of age, respectively, from 1.13 to 0.96, 1.32 to 1.19, and 1.48 to 1.26. The narrowing of mortality occurred among Whites and, to a lesser extent, Blacks. A relative increase in either breast cancer incidence among women in lower SES counties or improved survival among women in higher SES counties (reflecting greater use of screening and treatment) could account for this relative worsening of breast cancer mortality among lower SES women in lower SES counties.

A new defense: the maternity waiver program.

The Maternity Waiver Program is a freedom of choice waiver granted by the Health Care Financing Administration. A freedom-of-choice waiver allows certain sections of the Social Security Act to be waived, specifically statewide effectiveness; duration, amount and scope of benefits; and freedom of choice. The waiver allows the state to direct women to whom they can receive prenatal care. By restricting statewideness, the state can set up the program on a county by county basis. By waiving amount, duration and scope, the state can provide additional services to women in waiver counties that are not offered in nonwaiver counties (e.g., home visits). And by waiving freedom-of-choice, the state can set up a primary provider network which ensures that women have access to quality and comprehensive maternity services which are coordinated from the initial encounter through the postpartum period. The end result is a healthier birth outcome.

Style Preferences and Criteria for Selection of Home Furnishings by Rural Families

AbstractResearch suggests that the criteria used in making decisions about home furnishings differ among various population segments. This study identifies stylistic preferences, degree of satisfaction, and factors influencing the selection of living-room furnishings for women in rural Illinois counties. The counties were delimited by two factors: there could be no major metropolitan area in the county and populations of towns were 2,500 or less. The findings reveal a high degree of stability in home-furnishings choices of the 336 women sampled. They were generally satisfied with the present style of their upholstered furniture and expressed no desire to change styles in the future. “Style and look” was consistently noted as the most important consideration in selecting sofas and chairs. “Influence of family and friends” was listed overwhelmingly as the least important consideration.

Bladder cancer in pet dogs: a sentinel for environmental cancer?

Proportional morbidity ratios (PMRs) were calculated for cancers, by site or type, in 8760 pet dogs seen at 13 veterinary medical teaching hospitals in the United States and Canada. A significant positive correlation was seen between the PMRs for canine bladder cancer and the overall level of industrial activity in the host county of the hospital. An analysis of mortality from bladder cancer among white men and women in the same US counties showed similar correlations with industrial activity. Canine bladder cancer could be a sentinel condition whose investigation in locales might lead to early identification of carcinogenic hazards in the general environment.