Survivors of domestic violence: demographics and disparities in visitors to an interdisciplinary specialty clinic

Although the traditional response to domestic violence has been undertaken by legal and human service agencies, this societal issue has become increasingly recognized as a national public health concern. While identification and intervention in cases of domestic violence are widely recommended, little data exist on intervention outcomes. This retrospective study describes similarities and disparities in sociodemographic variables, health status, referral characteristics, and management strategies among patients referred to a specialty clinic for survivors of domestic violence.

Use of private gynaecologist does not relate to better prevention outcomes - an ecological analysis from Finland

BACKGROUND

Control of reproduction and prevention of reproductive health problems are important reasons for women to use health services, but the proper organisational level of service provision is not clear. The purpose of this study was to investigate whether visits to private gynaecologists correlate with better health outcomes and worse participation in organised screening for cancer programs.

METHODS

This is an ecological analysis using municipalities and groups of women at 5-year age intervals within municipalities as study units. First, the Finnish municipalities (n = 452) were classified into three groups by the age-adjusted level of use of private gynaecologists. Secondly, each age group within municipalities was classified into tertiles by the level of private gynaecologist use. The outcomes were participation in cervical and organised breast cancer screening for cancer programmes, stage of gynaecological and breast cancers at diagnosis, and abortion rates and ratios. All data were obtained from national registers by groups at 5-year age intervals and by municipality. Raw and adjusted (age groups, and in some analyses, municipality social class index) odds ratios, total and by urbanity, were calculated.

RESULTS

The proportions of women participating in cervical cancer and organised breast cancer screening for cancer were somewhat higher in the groups having a low use of private gynaecologists. The proportions of local cancers of all cervical, uterine, ovarian and breast cancers were similar in the three groups, even though the first analysis method suggested somewhat better results for the low-use group in case of cervical cancer and for the high-use group in case of uterine and breast cancer. The rates of induced abortion were higher in municipalities having a high use of private gynaecologists than in those having lower use.

CONCLUSION

This ecological analysis suggests that frequent use of private gynaecologists relates somewhat to lower organised screening for cancer participation, and is not better in preventing abortions or in detecting cancer earlier. Our results suggest that a planned system relying mainly on general practitioners and public health nurses as the first line care providers is equally good for women's reproductive health as that in which specialists are used.

Pain and Depressive Symptoms among Financially Disadvantaged Women's Health Patients

OBJECTIVES

Women are at greater risk than men for both pain and depression, yet little is known about the frequency and implications of comorbid pain and depression among women in women's health settings. This study aimed to determine the frequency of comorbid depressive symptoms and pain among a sample of gynecology outpatients and to evaluate the associations of comorbid pain and depressive symptoms with physical, emotional, and social functioning and abuse experiences.

METHODS

A total of 242 low-income, primarily African American women presenting at an urban women's health clinic for routine gynecological care consented to participate. Subjects completed the Beck Depression Inventory, Brief Symptom Inventory, Graded Chronic Pain Scale, SF-36, Physical and Sexual Abuse Questionnaire, and Duke Social Support Index. Multivariate analyses were used to test pain and depressive symptoms in their associations with emotional, physical, and social functioning and abuse experience. Age, race, income, and education were controlled in all analyses.

RESULTS

Nearly 20% of participants reported comorbid high depressive symptoms and pain. Both depressive symptoms and pain were independently associated with emotional, physical, and social functioning domains. Depressive symptoms, but not pain, were associated with increased likelihood of history of abuse.

CONCLUSIONS

Comorbid depressive symptoms and pain are a substantial problem, with pervasive implications among financially disadvantaged women seeking routine gynecological care. Subsequent research will determine if psychosocial treatment can be adapted effectively to the needs of this patient population.

Preventive health examinations: A comparison along the rural–urban continuum

In this analysis, Medical Expenditure Panel Survey data from 2000 were used to examine differences in reports of preventive health service utilization in 4 types of counties: large metropolitan counties, small metropolitan counties, counties adjacent to metropolitan places, and counties not adjacent to metropolitan areas or with fewer than 10,000 residents. Women from counties with 10,000 or fewer residents and not adjacent to a metropolitan county, classified as rural residents, were less likely to report a number of preventive health examinations during the previous 2 years. Rural women were less likely to obtain blood cholesterol tests, dental exams, and mammograms during the previous 2 years when compared to women from large metropolitan counties. Rural women were more likely to obtain blood pressure checks during the previous year when compared to the metropolitan women. Findings for exams that occurred during the preceding 1- and 2-year periods are reported for blood pressure checks, blood cholesterol checks, physical exams, colon cancer screening, dental exams, breast exams, mammograms, and Pap smears.

Women’s health care utilization and expenditures

This study examines women's use and expenditures for medical care in the US. In 2000, 91% of women aged 18 years and older used any form of health care services. Overall, 82% of adult women reported an ambulatory care visit, and 11% had an inpatient hospital stay. Mean expense per person with expenses was 3219 dollars for that year. We examined use and expenditures by sociodemographic characteristics. The most notable findings indicate that women with private insurance and those on Medicaid are more likely to use health services than uninsured women. White women, compared to black and Hispanic women, are more likely to have an ambulatory care visit, buy prescription drugs, and use preventive health care services. In addition, white and Hispanic women pay a higher proportion of medical care expenses out-of-pocket than do black women. Finally, nearly 30% of older women in fair or poor health spent 10% or more of their income on medical care. Preventable disparities in access to and receipt of care are unacceptable. To improve the quality of health care for all women, it is important for policymakers to understand the factors that influence their utilization and expenditures for medical care. Data collection, analysis, and reporting by race, ethnicity, and primary language across federally supported health programs are essential to help identify, understand the causes of, monitor, and eventually eliminate disparities.

Emergency contraceptive pills: a 10-year follow-up survey of use and experiences at college health centers in the mid-Atlantic United States

The authors conducted a 10-year follow-up study using a telephone survey to investigate the availability of emergency contraceptive pills (ECPs) at college health centers in the mid-Atlantic region of the United States. They also examined related issues, such as distribution procedure, existence of a written protocol, personnel involved, contraindications, follow-up procedures, methods of advertising, staff attitudes, changes in distribution over the past 10 years, and availability if ECPs become over-the-counter. Of the 119 completed responses, 58 schools (49%) reported distributing ECPs. The most common reasons schools listed for not distributing ECPs (n = 61, 51%) were religious convictions, understaffing, and lack of funding. Major changes in ECP distribution over the past 10 years related primarily to the number of schools distributing ECPs, protocol in ECP distribution, and advertising for ECP services.

Quality of health care for older women: What do we know?

As the proportion of the population age 65 and over continues to grow--to a projected 20.5% or 77.2 million by the year 2040--tracking the quality, access, and receipt of care for older women becomes more important, since the majority of older citizens are women. This article establishes a rough baseline for the quality of care, primarily preventive care, received by older women compared to older men, using selected measures and data of the 2004 National Healthcare Quality Report and National Healthcare Disparities Report. It highlights significant differences between women and men, as well as differences for racial, ethnic, and educational subgroups. Generally, older non-Hispanic white women frequently score higher than their Hispanic and non-Hispanic black counterparts, and more educated women often score significantly higher than their less-educated peers on several measures of quality of care. Compared to their male counterparts, older women are significantly less likely to have any colorectal screening test, to keep high blood pressure under control, and to receive aspirin or beta-blockers upon hospital admission or discharge for acute myocardial infarction. Results are mixed for the process measures related to diabetes, but improvements are clearly needed toward increased rates of eye and foot examinations. Rates of influenza and pneumococcal vaccinations are low but can be improved through Medicare-covered services. We also found that older women are screened less often for breast cancer than those ages 40 to 64. There is still a pervasive lack of knowledge in the research and clinical communities about the unique health care needs of and appropriate processes of care for older adults. More research needs to focus on the quality of care for this growing population in order to allow the development of geriatric-based quality measures and models of care that will set the standards of healthcare for older adults in general, and older women in particular.

[Female circumcision--complications and treatment]

The majority of women with extensive forms of genital cutting develop one or more chronic complications such as dysmenorrhea, dyspareunia, pain and cysts in the perineum, vaginal obstruction with haematocolpos, relative urine retention and recurrent urinary tract infections. Extensive forms of circumcision also influence childbirths. The severity of the cutting is associated with the probability of developing later complications. The women's clinics at the regional hospital in Norway have established outpatient clinics to receive women with complications after genital cutting. The aim was to develop an adequate health service to the affected. In order to improve the access to care and to ensure anonymity the women may refer themselves. During 2004, a total of 60 women were treated. The majority suffered from poor urinary flow, pain at micturition, dysmenorrhea and dyspareunia. Reconstruction of the vaginal orifice was performed to relieve some of the discomforts. The numbers of women who visit the clinics are increasing. The surgical procedure itself is not technically difficult, but the consultation before and after the surgery require cultural sensitivity. As health care personnel we can influence the affected to realise that genital cutting is an assault against a small girl. Norwegian health care workers need to learn more about how to communicate well about the medical as well as the cultural and mental aspects of genital cutting.

Health care for women with disabilities: population-based evidence of disparities

Despite having similar or better potential access to health care, women with disabilities experience worse health care and worse preventive care than nondisabled women. This study examined the health care of a national probability sample of 8,721 disabled and 45,522 nondisabled women living in the United States. Logistic regression models, adjusted for age and household income, were estimated for eight measures of health care, including three measures of potential access to care, two measures of receipt of preventive services, and postponement of care. Findings signal potentially serious consequences for women with disabilities, who require care at higher rates than their nondisabled counterparts and are at increased risk of developing secondary conditions if their care needs are not met.

Women's experiences of and preferences for services after rape in South Africa: interview study

OBJECTIVES

To describe aspects of delivery of health services after rape, including trade-offs, that would most influence choice of service, and to compare views of patients who had used such services with views of members of the community who may be future users or may have experienced barriers to service use.

DESIGN

Discrete choice analysis of stated preferences with interviews. Attributes included travel time to the service, availability of HIV prophylaxis, number of returns to the hospital, medical examination, and counselling skills and attitude of the provider.

SETTING

One rural and one urban site in South Africa.

PARTICIPANTS

319 women: 155 who had been raped and four carers recruited through health facilities and 160 comparable women recruited from the community. Of these, 156 were from an urban site and 163 from a rural site.

MAIN OUTCOME MEASURES

Strength of preferences over a range of attributes through the estimation of a benefit function through random effects probit modelling.

RESULTS

Factors such as the availability of prophylactic treatment for HIV infection and having a sensitive healthcare provider who could provide counselling are more important in women's decisions to seek care after rape than the travel time necessary to access those services.

CONCLUSION

Our findings support the need for holistic rape services.

Increased health care utilisation among 10-year breast cancer survivors

OBJECTIVE

We investigated self-reported health care utilisation of women who survived breast cancer for 10 years and identified predictors of health care utilisation.

METHODS

The population-based Eindhoven Cancer Registry was used to select all women who were diagnosed with breast cancer in 1993, in six hospitals in the Netherlands, and were disease-free at the time of data collection. Health status, psychological well-being, satisfaction with life and health care use were compared with same age controls. Logistic regression was used to identify predictors of health care utilisation.

RESULTS

Of the 254 women who were sent a questionnaire, 183 (72%) responded. Breast cancer survivors had a similar health status and psychological well-being and a better satisfaction with life compared to same age controls. The proportion of breast cancer survivors (79%) who visited a specialist in the past 12 months was significantly higher compared to controls (53%). Young breast cancer survivors (45-54 at time of completing questionnaire) more often visited a physical therapist (56%) or complementary caregiver (26%) than controls (29 and 13%, respectively). Spontaneously reported problems (fatigue, arm problems) as a consequence of cancer and co-morbidity showed the strongest associations with health care utilisation.

CONCLUSIONS

Although self-reported health, satisfaction with life and psychological well-being were similar or even better in long-term breast cancer survivors compared to those in population controls, survivors more often attended a specialist, physical therapist and complementary caregiver in the past 12 months. Survivors of young age appear to have the highest use of health care services compared to age-matched controls, especially related to fatigue and arm problems.

The role of education in the uptake of preventative health care: the case of cervical screening in Britain

This paper reports findings on the relationship between education and the take-up of screening for cervical cancer, as an example of preventative health-care activity. Theoretically, education can enhance the demand for preventative health services by raising awareness of the importance of undertaking regular health check-ups and may also improve the ways in which individuals understand information regarding periodical tests, communicate with the health practitioner, and interpret results. Furthermore, education enhances the inclusion of individuals in society, improving self-efficacy and confidence. All these factors may increase service uptake. The empirical analysis uses data from the British Household Panel Survey (BHPS) and applies techniques for discrete panel data to estimate the parameters of the model. Results show that adult learning leading to qualifications is statistically associated with an increase in the uptake of screening. The marginal effect indicates that participation in courses leading to qualifications increases the probability of having a smear test between 4.3 and 4.4 percentage points. This estimate is strongly robust to time-invariant selectivity bias in education and the inclusion of income, class, occupation, and parental socio-economic status. These findings enrich existing evidence on the socio-economic determinants of screening for cervical cancer and enable policy makers to better understand barriers to service uptake.

Brutal neglect: Australian rural women's access to health services

Access to health services in rural Australia has been particularly problematic because of the vast geographical areas and the sparse population distribution across the inland. The focus on health servicing has been very much on primary health care with most attention being giving to the distribution of doctors in rural Australia. This study takes a closer look at rural health servicing through the eyes of women in rural Australia. Drawing on a survey of 820 women, the study revealed that a focus on primary health care may be resulting in a lack of attention to women's health in areas, such as maternity models of care, domestic violence and mental health. The study also reveals the disquiet of Australian rural women at the poor state of health services.

[ENCOPREVENIMSS 2003, 2004 AND 2005. 3. Advances in Women, Men and Seniors' Health Programs]

This paper presents the results of the National Survey of Coverage of Integrated Health Programs (ENCOPREVENIMSS) 2003, 2004 and 2005, with regard to the coverage of Women, Men and Seniors' Health Programs. ENCOPREVENIMSS are nationwide probabilistic population-based surveys with delegation (state) representativeness of insured population of the Mexican Institute of Social Security. The sampling frame was stratified, with several stages, and by clusters. The surveys gathered information of sociodemographic characteristics, use of health services and coverage of the main components of the Health Integrated Programs (PREVENIMSS), as well as other complementary variables. For the purpose of this article, the main variables studied were those related to health promotion, weight, height and waist measurement, as well as other related to early detection of certain diseases. The results show an increase in the coverage during the period 2003-2005 in the three groups; however, the lowest were found in the group of men from 20 to 59 years old and the highest, in the group of seniors older than 59, except for those related to the detection of cervical and breast cancer, which were higher in women from 20 to 59 years old. Coverage analysis is useful to ascertain the degree of imposition of the different preventive activities and it is also a good basis for planning.

A profile of female residents of Pennsylvania

Specific information on the health of the women in Pennsylvania emphasizes the need for increased attention to needs of the more than six million female residents of the state.

Comparisons of Colorado Women’s Cancer Screening Practices by Residence: Metropolitan, Non-metropolitan, and Farm

Combining farm residents and non-farm rural residents into a single category designated as rural may obscure differences in preventive care utilization, including cancer screening practices in each group, because of distinctive characteristics of farmers. This study compared three cancer screening practices (mammography, breast physical examination, and Pap smears) across three residence groups (metropolitan, non-metropolitan, and farms) of Colorado women and described demographic and socioeconomic characteristics of the groups. Females interviewed in the 1993 Colorado Behavioral Risk Factor Surveillance System (BRFSS) were divided into residence as metropolitan or non-metropolitan. Farm residents were female respondents interviewed as part of the Colorado Farm Family Health and Hazard Survey (CFFHHS) conducted in 1993-1997. Univariate and multivariate analyses were conducted to determine characteristics related to the screening practices. Farm women were more likely to be non-Hispanic white and older, to report their health as very good, and to have medical insurance and at least one source of primary care compared to non-metropolitan women. After controlling for related variables, residence was not associated with the screening practices, with the exception of breast physical examination; farm women were less likely to have a recent examination than metropolitan women (OR = 1.50, 95% CI = 1.07-2.10). When non-metropolitan and farm women were combined, there was no association between residence and having had a physical breast examination. There were important differences between non-metropolitan women and farm women in demographic and socioeconomic characteristics, which influenced screening practices. Further studies are needed to examine farm residents' cancer screening practices separately from other rural residents in order to fully understand the implications of these differences for health status in other geographic areas.

Outcomes for women with co-occurring disorders and trauma: program-level effects

Program-level effects at 6 months are reported from meta-analysis of a nine-site quasi-experimental study of comprehensive, integrated, trauma-informed, and consumer-involved services for women who have mental health problems, substance use disorders, and who have experienced interpersonal violence. The average weighted effect size is significant for the treatment condition for improved post-traumatic symptoms (p < 0.02), drug use problem severity (p < 0.02), and nearly significant for mental health symptoms (p < 0.06). There is significant heterogeneity in effect sizes across sites. Program-level variables were examined in an effort to explain this heterogeneity. The findings indicate that sites which provided significantly more integrated counseling produced more favorable results in mental health symptoms (p < 0.01) and both alcohol (p < 0.001) and drug use problem severity (p < 0.001). The same trend is observable for reductions in post-traumatic stress symptoms, although the difference does not attain statistical significance.

Outcomes for clients of public substance abuse treatment programs before and after Medicaid managed care

Following conversion of Medicaid substance abuse treatment programs in Oregon from fee-for-service to managed care, there were suggestions of poorer outcomes. This project interviewed cohorts of Medicaid and non-Medicaid substance abuse treatment clients before and after the 1995 implementation of Oregon's Medicaid capitated payment system. Subjects were 553 adults (59% male, average age 35, 64% white). Forty-three percent were Medicaid clients and 60% were treated during the fee-for-service era. All clients were interviewed with the Addiction Severity Index at baseline and at 6 and 12 months thereafter. Multilevel, multivariate analyses examined baseline and outcome differences between the Medicaid and Non-Medicaid groups; between the fee-for-service and managed care conditions; and their interactions. After adjustment for covariates, most analyses were not statistically significant. It does not appear that Medicaid managed care had an adverse impact on outcomes for clients with substance abuse problems.

Outcomes for women with co-occurring disorders and trauma: program and person-level effects

Six-month outcomes are evaluated from a 9-site quasi-experimental study of women with mental health and substance use disorders who have experienced physical or sexual abuse who enrolled in either comprehensive, integrated, trauma-informed, and consumer/survivor/recovering person-involved services (N = 1023) or usual care (N = 983). Mental health, post-traumatic stress symptoms, and substance use outcomes are assessed with multilevel regression models, controlling for program and personal characteristics. Person-level variables predict outcomes independent of intervention condition and, to a small extent, moderate intervention and program effects. In sites where the intervention condition provided more integrated counseling than the comparison condition, there are increased effects on mental health and substance use outcomes; these effects are partially mediated by person-level variables. These results encourage further research to identify the longer-term effects of integrated counseling for women with co-occurring disorders and trauma histories.

The association between women’s health information use and health care visits

OBJECTIVE

To determine the effect of the type of information sources used on health services use.

METHODS

Population-based random-digit dialing survey of 498 women, between December 1999 and January 2000, on use of health information sources and health visits.

RESULTS

After adjustment for sociodemographic and medical factors, use of print health media and computer-based resources was associated with 1.9 and 1.6 more visits, respectively compared to non-use (Regression coefficients 1.9; [95% confidence interval {CI} 0.1, 3.7] and 1.6; [95% CI 0.3, 3.0]).

CONCLUSIONS

Print health media and computer-based sources are associated with a higher number of health care visits.

Does diabetes care compete with the provision of women's preventive care services?

OBJECTIVE

Care for chronic diseases may compete with preventive health care. To test this hypothesis, we examined the association between diabetes-related processes of care and preventive care in women.

RESEARCH DESIGN AND METHODS

Using data from a prospective cohort study of diabetes care in managed care settings, we reviewed the care 540 diabetic women received from 355 primary care providers within 14 provider groups from one health plan. Of the 540 women, 278 were eligible to receive mammograms and 314 were eligible to receive Pap smears. Mammography performance was measured as at least one mammogram over a 2-year period and Pap performance was measured as at least one Pap smear over a 3-year period. To assess the association between diabetes-related processes of care and preventive services, we used hierarchical logistic regression models, accounted for clustering within provider groups, and adjusted for patient age, race, income and education level, diabetes treatment and duration, and health status, as well as physician age, sex, years of practice, and specialty. Diabetes-related processes of care were defined as dilated retinal examinations, urine microalbumin/protein testing, foot examinations, lipid and HbA(1c) testing, recommendations to take aspirin, and influenza vaccinations received over a 1-year period.

RESULTS

In this cohort, 73% of eligible women received mammograms and 56% received Pap smears. After adjustment of models, better diabetes-related processes of care, better health status, and non-Medicaid insurance were associated with mammography performance. Better diabetes-related processes of care, younger patient age, and any visit to a gynecologist were associated with Pap performance.

CONCLUSIONS

Better processes of diabetes care were associated with better women's preventive health care. Diabetes management did not compete with sex-specific screening.

Assessing the economic impact of chronic conditions in postmenopausal women

The ageing of the US population and the recognised importance of preventative care has led to a growing body of research regarding the morbidity and mortality associated with chronic diseases in postmenopausal women. According to the National Institute of Health, postmenopausal women have a significant increase in risk for a number of debilitating diseases, including osteoporosis, breast cancer and cardiovascular disease. In addition, recently published studies prompted patients, clinicians and payers to re-examine the risks and benefits of a well-accepted therapy to treat postmenopausal symptoms. The objective of this paper is to provide a framework for assessing the economic impact of disorders affecting postmenopausal women, with a particular focus on osteoporosis, breast cancer and cardiovascular disease. This framework considers the prevalence of these conditions, the profiles of women suffering from each of them and prevailing patterns of treatment for these disorders. Taken together, these factors are used to analyse the overall economic impact of postmenopausal disorders and to provide an expert opinion in this context.

Depression among female family planning patients: prevalence, risk factors, and use of mental health services

BACKGROUND

Depression is a common, yet underdiagnosed mental health problem among women of reproductive age. Whereas risk factors and treatment of depression have been well studied among women of all ages, little attention has been paid to the prevalence of depression and clinical outcomes of clinical depressive symptoms among women who visit public family planning clinics.

METHODS

A total of 588 female patients of three North Carolina health department family planning clinics were screened for their depressive symptoms. Women who screened positive for depressive symptoms during the initial assessment were referred for further mental health evaluation and treatment. Multivariate logistic regression was performed to examine risk factors of depressive symptoms, and a flow chart was used to demonstrate referral process and outcomes.

RESULTS

Approximately half of the women in the study evidenced high levels of depressive symptoms that were consistent with having a clinically relevant mental health problem. Results from multivariate analysis found that being classified as currently depressed was significantly associated with previous treatment for depression (OR = 5.43), no social support (OR = 3.57), and unemployment (OR = 3.21). Caucasians were significantly more likely than African Americans to be depressed (OR = 2.63), and teenagers and women with low levels of education were more likely to evidence depression (OR = 1.99 and OR = 1.78, respectively). Few of the patients who were classified as depressed and were referred for further mental health evaluation followed through with the referrals.

CONCLUSIONS

These findings underscore the importance of providing routine screening of women for depression within the context of family planning services and providing referrals, follow-up, and mental health treatment to those women in need.

A Community-Based Intervention to Increase Screening Mammography Among Disadvantaged Women at an Inner-City Drop-In Center

PURPOSE

To determine the effectiveness of a community- based intervention to increase the use of screening mammography among disadvantaged women at an inner-city drop-in center.

METHODS

This study involved women 50 to 70 years old who were clients of an inner-city drop-in center in Toronto, Canada, during the years 1995-2002 (N = 158 in 1995-2001 and N = 89 in 2002). In 2002, the drop-in center and a nearby hospital initiated a collaborative breast cancer screening project in which a staff member of the drop-in center accompanied small groups of women for mammography visits at a weekly pre-arranged time. Interrupted time series analysis was used to examine the effect of this intervention on the annual rate of screening mammography, as determined by review of medical records.

RESULTS

More than half of the women 50 to 70 years old who used the drop-in center in 2002 had been diagnosed with a major mental illness, and one-third were either homeless or living in supportive housing. In the 7 years before the introduction of the intervention, annual mammography rates among women using the drop-in center averaged 4.7%. During the intervention year, 26 (29.2%) of 89 women underwent mammography (p = 0.0001 for the change from pre-to post-intervention).

CONCLUSIONS

The introduction of accompanied small-group visits was associated with significantly increased use of mammography in a group of disadvantaged women who were clients of an inner-city drop-in center. This approach may be useful to promote breast cancer screening among women affected by mental illness or homelessness who have contact with community-based agencies.