Women in residential drug treatment: differences by program type and pregnancy

This study compared the characteristics of 4,117 women treated in publicly funded residential drug treatment programs in Los Angeles County between 1987 and 1994 by pregnancy status and program gender composition, that is, women-only and mixed-gender programs. A logistic regression analysis determined the predictors of program completion. Women in women-only programs were more likely than women in mixed-gender programs to be pregnant, homeless, or on probation; to use methamphetamines; to use alcohol; and have prior drug treatment. Pregnant women were younger, more likely to be homeless, had fewer years of drug use, were more often referred by other service providers, and were less likely to have injected drugs or have prior drug treatment than non-pregnant women. Although women in women-only programs had more problems, they spent more time in treatment and were more than twice as likely to complete treatment as compared with women in mixed-gender programs.

Security and safe havens: health issues among women in mobile homes

This paper is based on a small study of women resident in caravan parks. The study, undertaken in the context of the Australian Longitudinal Study on Women's Health, explored the health status and the health seeking behavior of women living in mobile homes in two townships in north coast New South Wales, Australia. Older women had moved to park accommodation, some with husbands, to escape the financial strains of maintaining larger homes on fixed incomes. Younger women, in contrast, typically moved to the parks alone or with children but without an adult partner, and were motivated to move from more permanent housing as a result of financial hardship, domestic violence, and their own or partners' drug and alcohol abuse. We had hypothesized some differences in women's health status and health related behavior according to place of residence, because of the differences in the two townships with respect to infrastructure and social characteristics. However, women's health status varied primarily according to age. Women believed they were physically healthy, although with some dental, sexual and particularly mental health problems.

Health care utilization and satisfaction concerning gender-specific health problems among military women

There is growing concern regarding the quality of gender-specific health care for military women in general and for female veterans of the Persian Gulf War in particular. This paper reports on health care utilization rates for gender-specific problems and describes differences in these rates among age, rank, and component groups of a randomly selected sample of military women. Study findings provide preliminary evidence for a closer examination of health care services for women within the armed forces, particularly within specific cohorts, to better target both services and policy.

[Management and performance of human resources in reproductive health services]

For most people, utilizing reproductive health services is colored by strong emotional and subjective implications. Therefore, it is essential to know the local situation well when planning those services and designing activities directed toward the community. User satisfaction also depends on allowing those persons to participate in solving problems from their own perspective and on the treatment they receive from health service personnel. It's impossible to overstate the importance of the performance of health care providers and, accordingly, the management of those personnel. This article presents general principles that govern such management, the tasks that management entails, and the most desirable attitudes in reproductive health service providers.

Increased cardiopulmonary disease risk in a community-based sample with chemical odor intolerance: implications for women's health and health-care utilization

Chemical intolerance, or reported illness from odors of common environmental chemicals (e.g., car exhaust, pesticides), is emerging as an important environmental and public health-care issue. Epidemiologic methods provide relevant heuristic devices for studies of complex disorders, such as chemical intolerance. The authors examined personal and reported parental cardiopulmonary disease prevalence rates in a community sample of chemically intolerant and control individuals. A county government (Tucson, Arizona) employee and kin subset (N = 181; 113 households) completed standard health questionnaires. Investigators determined chemical intolerance (n = 41/181) from self-reports of individuals who felt "moderately" to "severely" ill from exposure to at least three of five chemicals (i.e., car exhaust, pesticides, paint, new carpet, and perfume) on a Chemical Odor Intolerance Index. The authors chose the control group (n = 57/181) on the basis of self-reports of "never" feeling ill on the Chemical Odor Intolerance Index. The chemically intolerant group, which primarily comprised women (78% versus 51% of controls, p < .05), was significantly more likely to report-and to have sought--medical attention for heart problems, bronchitis, asthma, and pneumonia. Reports of heart problems in the chemically intolerant index cases and the occurrence of heart disease in both of their parents were significant (Fisher's p < .05). The chemically intolerant individuals were also significantly more likely to report maternal histories of chest problems (e.g., inhalant allergens, tuberculosis) than controls. The findings of the study suggested that the chemically intolerant individuals (a preponderance of whom were women [sex-related risk]) were more likely to have (a) reported cardiopulmonary problems (i.e., greater health risk); (b) actively sought medical care for these problems (i.e., increased medical utilization); and (c) reported more parental illnesses-particularly heart disease, asthma, and diabetes (i.e., genetic risk). Additional community-based studies of chemical intolerance are needed.

Effect of mammography outreach in women veterans

We undertook this study to test whether progressive intervention would increase the use of mammography. In 1995, we randomly assigned into 2 groups 717 underserved women veterans in the Veterans Affairs Palo Alto (California) Health Care System (VAPAHCS) who earned less than $22,000 a year. The women were sent an informational letter and brochure explaining why mammography is needed and how often. The letter further requested that if the woman was due for a screening mammogram or if a lump or other recent change in her breast had occurred, that she call for scheduling of a free mammogram and a visit to the breast clinic. Women in group I (n = 351) received no further intervention. Women in group II (n = 366) received a follow-up phone call by a breast care nurse if they had not responded within 45 days of the informational mailing. The nurse talked to each woman about her particular needs, explained to her that the screening mammogram would be provided free of charge, and discussed transportation arrangements to the mammography facility. A total of 17 women in group I had mammograms versus 100 in group II during the same time period. We conclude that the additional intervention of a phone call by a breast care nurse increased use by more than 5-fold, which reached significance (P < .01).

A survey of women's health care needs on U.S. Navy ships

A total of 628 female and 526 male U.S. military personnel completed a health survey questionnaire at the completion of four shipboard deployments lasting 10 to 180 days (mean, 57 days). During deployment, women visited clinic (sick call) at significantly higher rates than men: 189 versus 117 visits per week per 1,000 personnel. Except for generally minor gynecological conditions, women and men had similar medical problems. Upper respiratory complaints and requests for contraceptive pills were the most common reasons for clinic visits among women. The majority of sailors felt that they had received appropriate medical care, although fewer women (66%) than men (78%) were satisfied. Levels of cigarette and alcohol use and sexual activity were comparable among women and men and corresponded to those of the general U.S. population of young adults. Because of high levels of health, most medical needs of women sailors can be managed readily by providing routine gynecological care and by minor additions to the shipboard pharmacy.

Sex differences in the use of health care services

BACKGROUND

Sex differences in the use of health care services can be substantial at several stages of life. However, the extent to which differences in reproductive biology and mortality affect the use of health care services is unclear.

METHODS

We studied age- and sex-specific per capita use of health care resources for a one-year period during 1994 and 1995 in the Canadian province of Manitoba, where there is universal insurance for a comprehensive range of health care services. Using information obtained from administrative records of physicians' services and acute hospital care, we tabulated the use of health care resources by male and female subjects in three categories: care for conditions specific to sex, care provided to persons who died during the study year, and care provided for all other conditions.

RESULTS

The crude annual per capita use of health care resources (in Canadian dollars) was greater for female subjects ($1,164) than for male subjects ($918). Approximately 22 percent of health care expenditures for female subjects was associated with conditions specific to sex, including pregnancy and childbirth, as compared with 3 percent of expenditures for male subjects. An estimated 14 percent of health care expenditures for male subjects was consumed by persons who died during the study period, as compared with 10 percent of expenditures for female subjects. After adjustment for the use of health care associated with sex-specific conditions and differences in mortality, the female:male ratio in health care expenditures was reduced from 1.3 to 1.0.

CONCLUSIONS

Expenditures for health care are similar for male and female subjects after differences in reproductive biology and higher age-specific mortality rates among men have been accounted for.

Dental utilization by low-income mothers

OBJECTIVE

This study examines the influence of predisposing, enabling, and need variables on whether low-income mothers sought dental care during the past year. This report is a substudy of mothers and children on their self-reported health status, utilization, access, and satisfaction with health care in general.

METHODS

A convenience sample of 502 mothers and youngest child younger than 6 years old was administered a face-to-face questionnaire in four Ohio counties. Information was collected at county human services offices and WIC clinics between November 1995 and July 1996. Using whether or not the mother sought dental care as the dependent variable, logistic regression models were created for the variables within the predisposing, enabling, and need characteristics separately and together.

RESULTS

Fewer than one-half of the mothers sought dental care during the past year. Variables associated with the predisposing characteristic explained little about who sought care. Those mothers who have Medicaid coverage are 2.7 times more likely to have a dental visit than those without insurance. Moreover, those mothers who perceive any dental need are several times less likely to have received dental care than those who have no perceived need.

CONCLUSIONS

Even among a somewhat homogeneous population of low-income women, source of payment for dental services and perceived need for dental care are discriminating variables in determining who seeks dental care.

Reproductive tract infections in primary healthcare, family planning, and dermatovenereology clinics: evaluation of syndromic management in Morocco

OBJECTIVE

To determine where and with what symptoms women seek care for reproductive tract infections (RTI) in Morocco and to guide allocation of resources for training and treatment for RTIs.

METHODS

A primary healthcare centre (PHC), a family planning centre (FPC), and a specialty dermatovenereology clinic (SC) were selected in each of three urban areas. Women with symptoms of vaginal discharge, lower abdominal or pelvic pain, or genital lesions (genital ulcer or warts) underwent interviews, physical examinations, serological testing for human immunodeficiency virus (HIV) and syphilis, and collection of vaginal fluid for microscopic examination, and urine for detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) by ligase chain reaction (LCR).

RESULTS

Over 8 months, 1238 women enrolled, including 61.8% at PHCs, 34.8% at FPCs, and 3.4% at SCs. Overall, 54% complained of vaginal discharge, of whom 8.8% had GC or CT infection and 30.1% had trichomoniasis (TV) or bacterial vaginosis (BV); 24.9% complained of lower abdominal pain with or without vaginal discharge, of whom 7.3% had GC or CT and 22.6% had TV or BV. GC or CT infections were found in 10.1% of PHC and 5.4% of FPC patients; while TV and/or BV infections were found in 28.7% and 22.8%, respectively. GC or CT infection was associated with perceived risk behaviours of the male partner (for example, belief partner is unfaithful) more often than with reported risk behaviours of the women themselves. For vaginal infections, a modified World Health Organisation (WHO) test algorithm for vaginal discharge involving risk assessment plus speculum and bimanual examination was 98.0% sensitive at PHCs and 90.8% at FPCs, with positive predictive value (PPV) of 33.4% at PHCs and 26.8% at FPCs. For GC or CT infections this algorithm was 60.6% sensitive at PHCs and 85.7% sensitive at FPCs; but PPV was only 9.9% and 9.0% respectively, little higher than the background prevalence of these infections. An RTI algorithm (Morocco specific) had comparable sensitivity and PPV for vaginal infection, and for cervical infection was less sensitive but had much higher PPV (26.9% for PHCs and 26.7% for FPCs).

CONCLUSION

Women with complaints of vaginal discharge and/or lower abdominal pain presented to PHC and FP clinics, not to SCs. PHCs and FPCs should therefore receive resources for management of vaginal discharge. Both the test algorithm and the new RTI algorithm were useful in allocating treatment for vaginal infection, but only the RTI algorithm discriminated in selecting women with cervical infection. Even with the RTI algorithm, which limited treatment for cervical infection to risk assessment positive patients with signs of cervical infection or PID, the PPV for cervical infection was low, potentially resulting in frequent overtreatment and problems of partner notification.

The supermarket for women's reproductive health: the burden of genital infections in a family planning clinic in Nairobi, Kenya

OBJECTIVES

To study the burden of disease of reproductive tract infections (RTIs) and cervical dysplasia in women attending a family planning clinic in Nairobi, Kenya, and to assess the acceptability of integrating reproductive healthcare services into existing family planning facilities.

METHODS

In a family planning clinic in Nairobi, Kenya, 520 women were enrolled in a study on RTI and cervical dysplasia.

RESULTS

RTI pathogens were detected in over 20% of women, the majority being asymptomatic. HIV-1 testing was positive in 10.2%. The diagnosis of cervical dysplasia was made on 12% of the cytology smears (mild in 5.8%, moderate in 3.5%, severe in 1.2%), and 1.5% had invasive cervical cancer. The intervention of case detection of RTI and Papanicolaou smear taking was well received by clients and considered feasible by the staff.

CONCLUSIONS

Early detection and treatment of potentially curable cervical lesions and RTI provide a unique opportunity to improve women's health. In Kenya, where the current contraceptive prevalence rate is 33%, family planning clinics are excellent sites to introduce health interventions.

Age, ethnicity, and comorbidity in a national sample of hospitalized alcohol-dependent women veterans

OBJECTIVE

Treatment patterns in a national sample of hospitalized women veterans diagnosed with alcohol dependence were identified with the goal of improving health services to women veterans with alcohol-related disorders.

METHODS

Information from VA's patient treatment file for fiscal year 1993 was used to identify 854 women veterans diagnosed with alcohol dependence. Of that group, 546 received a primary diagnosis of alcohol dependence, and 308 received a secondary diagnosis of alcohol dependence after they sought treatment for other health problems. Chi square tests and multivariate logistic regression analyses were used to examine relationships between the sociodemographic profiles of these women and the types of services they received.

RESULTS

The study population's largest age group (49 percent) was 30 to 39 years old. Fifty-two percent of the women were divorced or separated, and 62 percent were Caucasian. The overwhelming majority of comorbid diagnoses were of psychiatric disorders. Overall, only 47 percent of the 854 patients received formal treatment for their alcohol disorder, and only 34 percent completed alcohol treatment. Women over age 60 were significantly less likely than women in other age groups to enter or complete formal treatment. Native-American women were significantly more likely than Caucasians or African Americans to receive formal alcohol treatment services.

CONCLUSIONS

The results indicate a need for targeting interventions more effectively in certain groups of women veterans diagnosed with alcoholism. Low completion rates also suggest a need for greater incentives for patients to complete treatment programs.

Preventive health care for mentally ill women

Utilization of preventive medical care was compared for two low-income groups--47 women with serious mental illness in an urban mental health center and 17 women patients at a primary care center. Appropriate preventive care was defined as at least one physical examination, a Pap test, and a breast examination in the past five years and a mammogram if the patient was over age 40. Receipt of preventive care by women in both settings was similar. Histories of physical and sexual abuse were prevalent in both groups, and a history of abuse was associated with less frequent receipt of preventive care. Results indicate that procedures to identify and provide services to women with abuse histories should be further developed.

The relationship of clinic experience with advanced HIV and survival of women with AIDS

OBJECTIVE

Hospital and physician experience have been linked to improved outcomes for persons with HIV. Because many HIV-infected patients receive care in clinics, we studied clinic HIV experience and survival for women with AIDS.

DESIGN

Retrospective cohort study of women with AIDS whose dominant sources of care were clinics. Clinic HIV experience was estimated as the cumulative number of Medicaid enrollees with advanced HIV who used a particular clinic as their dominant provider up to the year of the patient's AIDS diagnosis: low experience (< 20 patients), medium (20-99 patients), high (> or = 100 patients). Proportional hazards models examined relationships between experience and survival.

SETTING

A total of 117 New York State clinics.

PATIENTS

A total of 887 New York State Medicaid-enrolled women diagnosed with AIDS in 1989-1992.

MAIN OUTCOME MEASURE

Survival after AIDS diagnosis.

RESULTS

In later study years (1991-1992), patients in high experience clinics had an approximately 50% reduction in the relative hazard of death (0.53; 95% confidence interval, 0.35-0.82) compared with patients in low experience clinics. Adjusting for demographic and clinical variables, 71% of patients in high experience clinics were alive 21 months after diagnosis compared with 53% in low experience clinics. Experience and survival were not significantly associated in the early study years (1989-1990).

CONCLUSIONS

In more recent years, women with AIDS receiving care in high experience clinics survived longer after AIDS diagnosis than those in low experience clinics, providing further evidence of a relationship between provider HIV experience and outcomes.

Nonbattering presentations to the ED of women in physically abusive relationships

To determine which diagnoses in the emergency department (ED), apart from battering injuries, were more common among women who were living in physically abusive relationships than among women who were not, a study was conducted in 10 hospital-based EDs in two cities serving inner city, urban, and suburban populations. A total of 9,057 women between the ages of 19 and 65 years presenting to the EDs were eligible for the study. Medical records were reviewed, and a written questionnaire was used. The questionnaire was completed by 4,501 (73% of those asked, 59% of those eligible, and 50% of those presenting). Two hundred sixty-six (5.9%) were currently in a physically abusive relationship but not in the ED for battering injuries, and 3,969 (88.2%) were not currently in a physically abusive relationship. An additional 266 (5.9%) were positive, probable, or suggestive for battering injuries and excluded from diagnosis comparisons. Women in physically abusive relationships were more likely to be diagnosed with urinary tract infections, neck pain, vaginitis, foot wound, suicide attempt, and finger fracture. However, these represented only 19.8% of diagnoses in this group. The use of this knowledge alone to predict the presence of intimate violence in individual patients in the ED will not identify the majority of women at risk. These results suggest the use of routine inquiry for abuse in all women.

The relationship between obesity and medical utilization among women in a primary care setting

OBJECTIVE

This project was designed to explore the utilization of specific health care resources by obese compared with nonobese women in a primary care setting.

METHOD

Eighty-three obese women, consecutively identified during nonemergent appointments in a primary care health maintenance organization (HMO) setting, were compared with 111 nonobese women with regard to several parameters of health care utilization. All participants' medical records were reviewed for the preceding 12 months for the number of diagnoses, combined telephone and physician contacts with the facility, different physicians seen, and prescriptions.

RESULTS

Increasing body mass index (BMI) was predictive of a greater number of diagnoses, contacts with the facility, total number of prescriptions, and number of different physicians seen. After controlling for the number of diagnoses, BMI remained predictive of the number of different physicians seen.

DISCUSSION

Our findings indicate that increasing BMI is associated with greater health care utilization, primarily through greater morbidity. Additionally, there may also be particular psychosocial and illness factors which contribute to obese women's patterns of physician contact.

Health services use by urban women with or at risk for HIV-1 infection: the HIV Epidemiology Research Study (HERS)

OBJECTIVE

To characterize health services use by urban women with or at risk for HIV-1 infection enrolled in a prospective multicenter study.

METHODS

1310 women 16 to 55 years of age who were at risk for HIV-1 infection were recruited between April 1993 and January 1995 at four urban centers (Baltimore, Maryland; The Bronx, New York; Detroit, Michigan; and Providence, Rhode Island). HIV-1-seropositive women without AIDS-defining illness were oversampled in a ratio of 2:1 in comparison with HIV-1-seronegative women. At a baseline study visit, the women received physical and laboratory examinations, including CD4+ counts, and were interviewed regarding HIV risk behavior, health services use, and clinical data.

RESULTS

863 women were HIV-1-seropositive and 430 were HIV-1-seronegative. Fifty-two percent of the women reported injection drug use (IDU) since 1985, and 48% acquired HIV through sexual contact. Seventy-seven percent were African American, 23% were white, and 16% were Hispanic. The median age was 35 years. HIV-seronegative women were significantly less likely to have health insurance (19%) than were HIV-seropositive women (30%; p < .001). Among the HIV-seropositive women, 68% had CD4+ cell counts of <500/microl, and 64% were asymptomatic. Sixty-four percent of the HIV-seronegative women had had an outpatient hospital visit in the past 6 months, as had 86% of HIV-seropositive women (p < 0.001). Hospitalization in the past 6 months was also higher in HIV-seropositive women (22% vs. 12%; p < .001). Despite heavy use of health services, only 49% of women with CD4+ counts of <200/microl reported current use of antiretroviral therapy, and only 58% reported current use of Pneumocystis carinii pneumonia (PCP) prophylaxis. Among HIV-seropositive women, and after adjusting for CD4+ count, HIV symptoms, race, and study site, IDUs were significantly less likely to have a regular doctor and a recent outpatient visit and more likely to be hospitalized and use the emergency department (ED) than were non-IDUs. In multivariate analyses of HIV-seropositive persons, African American women had similar access to care and use of antiretroviral therapy and PCP prophylaxis than did white women but were less likely to have an outpatient department visit in the previous 6 months and to be taking PCP and opportunistic infection (OI) prophylaxis. Health services access and use of HIV-related therapies did not significantly differ between Hispanic and white women with HIV infection.

CONCLUSION

Although both HIV-seropositive and HIV-seronegative women had high levels of use of medical services, current use of antiretrovirals and OI prophylaxis was low throughout, and IDUs used HIV-related primary health services less and were more likely to receive emergency or episodic care. IDU and African American race were independently associated with decreased use of medical services.

Health-care-related attitudes and utilization among African American women

This study examined attitudes of African American women toward medical care and health insurance. Data were analyzed from the National Medical Expenditure Survey, a large household survey conducted by the Agency for Health Care Policy and Research and focusing on insurance and health care utilization. The responses of African American women tended neither to downplay the importance of receiving health care as essential to health maintenance and recovery from illness, nor to minimize health insurance as a worthwhile investment. When African American women did give responses discounting the importance of health care, the attitude difference failed to account for race-related differences in utilization. There was no evidence in the data to indicate that attitudes lead African American women to neglect seeking medical care or acquiring health insurance, and solutions to the problem of medical care underutilization must be sought elsewhere.

Quality of life, health care utilization, and costs among women undergoing hysterectomy in a managed-care setting

OBJECTIVE

We compared quality of life, utilization, and costs for women undergoing elective abdominal, laparoscopically assisted vaginal, or vaginal hysterectomy within a managed-care organization.

STUDY DESIGN

A prospective study of 287 women who underwent an elective hysterectomy was performed.

RESULTS

Patients undergoing a vaginal hysterectomy reported returning to normal activity levels sooner and had more favorable quality-of-life scores than did those undergoing laparoscopically assisted vaginal hysterectomy or abdominal hysterectomy. Laparoscopically assisted vaginal hysterectomy was often nearly as favorable as vaginal hysterectomy, particularly at 28 days after the operation, whereas the abdominal hysterectomy group consistently reported the poorest postoperative quality-of-life scores. No significant differences were noted in utilization or costs in the 60-day preoperative period, whereas hospitalization and postoperative costs were highest among the abdominal hysterectomy group and lowest for those undergoing a vaginal hysterectomy.

CONCLUSIONS

Vaginal hysterectomy resulted in better quality-of-life outcomes and lower utilization and costs compared with laparoscopically assisted vaginal or abdominal hysterectomy.

The health of Navajo women: findings from the Navajo Health and Nutrition Survey, 1991-1992

Cancer-screening behaviors, reproductive history, risk behaviors during pregnancy and chronic disease risk factors were examined in a representative sample of 566 Navajo women residing on the Navajo Reservation in 1991-1992. Among all women 15 y and older, 59% were overweight, 4% were current smokers, 10% currently used smokeless tobacco and 12% were anemic. Seventy-one percent of Navajo women aged 18 and older reported ever having had a Pap smear, but only 35% of women aged 50 and over reported ever having had a mammogram. Among parous women, the prevalence of having received no prenatal care for any pregnancy declined from 60% among women 60 and older to 13% among women 20-29 y of age, and the prevalence of ever having had a child born at home declined from 82 to 2%. These data suggest marked secular improvement in these pregnancy-related risk behaviors. However, data on cancer-screening behaviors indicate opportunities to improve health of Navajo women by increasing their use of mammography and Pap smear screening services.

Women's health care for the coming millennium

In examining ways to improve female health care access and utilization, the magnitude of health problems must be examined before the design of solutions. Two types of barriers interfere with health care: attitudinal barriers blocking motivation to seek health care services and organizational barriers which block actual use of needed services. The major health problems of women in the United States are heart disease, cancer, stroke, lung-related diseases, intentional injuries, diabetes and HIV/AIDS. Public health has had a greater impact than high technology on the health of our nation. Balancing health care reform, changes in legislation and funding for medical education should help the United States be responsive to the challenge to move from substandard health for many women to superlative health care for all women and their family members.