Protective orders in rural and urban areas: a multiple perspective study

This study is one of the first to examine the protective order process, barriers, and outcomes by combining qualitative and quantitative research in rural and urban areas. State statutes suggest the protective order process should be fair, consistent, and accessible to all women in the state. However, study results suggest that (a) the process of obtaining protective orders varies depending on community context; (b) although there are barriers to obtaining and enforcing protective orders regardless of geographic region, rural women appear to have more barriers; and (c) differences exist in victimization experiences, protective order stipulations, violations, and perceived effectiveness among rural and urban women.

Access to specialty mental health services among women in California

OBJECTIVE

The Anderson behavioral model was used to investigate racial and ethnic disparities in access to specialty mental health services among women in California as well as factors that might account for such disparities.

METHODS

The study was a cross-sectional examination of a probability sample of 3,750 California women. The main indicators of access to services were perceived need, service seeking, and service use. Multivariate models were constructed that accounted for need and enabling and demographic variables.

RESULTS

Significant racial and ethnic variations in access to specialty mental health services were observed. African-American, Hispanic, and Asian women were significantly less likely to use specialty mental health services than white women. Multivariate analyses showed that Hispanic and Asian women were less likely than white women to report perceived need, even after frequent mental distress had been taken into account. Among women with perceived need, African-American and Asian women were less likely than white women to seek mental health services after differences in insurance status had been taken into account. Among women who sought services, Hispanic women were less likely than white women to obtain services after adjustment for the effects of poverty. Need and enabling factors did not entirely account for the observed disparities in access to services.

CONCLUSIONS

Additional research is needed to identify gender- and culture-specific models for access to mental health services in order to decrease disparities in access. Factors such as perceived need and decisions to seek services are important factors that should be emphasized in future studies.

Chlamydia Screening of At-Risk Young Women in Managed Health Care: Characteristics of Top-Performing Primary Care Offices

OBJECTIVES

Despite effective approaches for managing chlamydial infection, asymptomatic disease remains highly prevalent. We linked administrative data with physician data from the American Medical Association physician survey to identify characteristics of primary care offices associated with best chlamydia screening practices.

STUDY

Criteria from the National Committee for Quality Assurance provided chlamydia screening rates. We defined top-performing offices as those with rates in the top decile among 978 primary care offices from 26 states.

RESULTS

Offices screened an average of 16.2% of at-risk, young women, but top-performing offices screened 42.2%. Top-performing offices on average had more black physicians (12.5%, 5.1%, P = 0.001) and were more often located in zip code areas with median income less than $30,000 (22.6%, 5.5%, P = 0.001).

CONCLUSIONS

Although chlamydia screening rates are alarmingly low overall, there is substantial variation across offices. Understanding predictors of better office performance may lead to effective interventions to promote screening.

Gender differences in smoking cessation services received among veterans

INTRODUCTION

Smoking is the leading preventable cause of death among women in the United States. It is a particular problem for women using the Veterans Health Administration (VA), where the prevalence of smoking among women is 30%. We compared the baseline characteristics of male and female smokers and then assessed the smoking cessation services they received to determine whether there are important gender differences in care.

METHODS

As part of a study of implementing national guidelines for smoking cessation taking place at 18/23 VA centers in the southwestern and western United States, we conducted a baseline survey of a random sample of 1,941 smokers in primary care (129 women, 1,812 men) to assess the smoking cessation services received by female and male veterans. Subjects were followed 1 year later (73 women, 1007 men). Results for men and women were compared using chi-square tests and analysis of variance. Logistic regression analyses were conducted to determine factors that were independently associated with receipt of smoking cessation services.

RESULTS

Female smokers were younger, more educated, and less likely to be married than male smokers. Women were equally likely to report being advised to quit smoking or referred to a smoking cessation program but were much less likely to report receiving a prescription for nicotine patches (OR .5, 95% CI .3-.9). One year later, female smokers were less likely to have successfully quit smoking.

CONCLUSION

Women were less likely to report receiving nicotine patches for smoking cessation. Future interventions to increase use of smoking cessation medications for female smokers will also hopefully increase their quit rate.

Quality-adjusted life years was a poor predictor of women's willingness to pay in acute and chronic conditions: results of a survey

OBJECTIVE

We investigated the relationship between quality-adjusted life years (QALYs) and willingness to pay (WTP) in acute and chronic conditions.

STUDY DESIGN AND SETTING

Face-to-face interviews were used to collect data in a convenience sample of women. Participants completed one interview evaluating preferences for an acute condition, post-chemotherapy nausea and vomiting (PCNV), and the other interview for a chronic condition (breast cancer). Preferences were elicited for QALYs using visual analogue scale (VAS), and standard gamble in addition to WTP. Because QALYs and WTP are purportedly based on the same underlying theoretical foundations, WTP was regressed onto change in QALYs, age, income, and health status.

RESULTS

Regression analysis reported statistically significant models for all breast cancer (P < .001) and PCNV (P < .05) conditions tested. However, QALY was not a significant predictor of WTP.

CONCLUSION

The results of this study indicate QALYs was a poor predictor of WTP for the conditions tested. Linear combinations of change in QALYs, age, income, and health status were a better predictor of WTP for chronic than acute conditions. This can be attributed to violations of underlying assumptions in measurement of QALYs with acute conditions and to problems with the use of WTP with chronic conditions.

Involving the community in cervical cancer prevention programs

Underutilization of cervical cancer prevention services by women in the high-risk age group of 30-60 years can be attributed to health service factors (such as poor availability, poor accessibility, and poor quality of care provided), to women's lack of information, and to cultural and behavioral barriers. The Alliance for Cervical Cancer Prevention (ACCP) partners have been working to identify effective ways to increase women's voluntary participation in prevention programs by testing strategies of community involvement in developing countries. The ACCP experiences include developing community partnerships to listen to and learn from the community, thereby enhancing appropriateness of services; developing culturally appropriate messages and educational materials; making access to high-quality screening services easier; and identifying effective ways to encourage women and their partners to complete diagnosis and treatment regimens. Cervical cancer prevention programs that use these strategies are more likely to increase demand, ensure follow-through for treatment, and ultimately reduce disease burden.

'Alukura ... for my daughters and their daughters and their daughters'. A review of Congress Alukura

OBJECTIVE

To describe the process, findings and limitations of a review of Congress Alukura commissioned in 1998.

METHODS

Analysis of documents and reports, service use and perinatal data from Alukura and the Northern Territory Midwives Collection; interviews with staff of Congress Alukura, of Central Australian Aboriginal Congress, of Aboriginal community organisations in Alice Springs and remote communities, of health care providers and other key informants in Alice Springs; community consultations through women's meetings or group discussions in local and remote communities. Interviews were coded for thematic and content analysis.

RESULTS

Client visits increased by 42% from 1995/96 (2130) to 1997/98. The proportion of women having a first trimester antenatal visit increased from 23% (1986-88) to 38% (1993-95). Mean birthweight of Aboriginal infants in the Alice Springs urban area was 3168 g in 1986-90, 3271 g in 1991-95, and 3268 g in 1996-99. Other primary and maternity care providers perceived the quality of care to be high and saw Alukura playing a key role through transport, liaison, screening and follow-up. Alukura was much less successful in its role as a place for birth. Expectations of additional outreach by local and remote communities were high.

DISCUSSION

The review's limitations included: a lack of direct input from young women, the main users of Alukura; a timeframe that precluded the detailed discussion necessary for seeking access to medical records, and the need for interpreters in community settings. Current and former staff who participated in the review often had other important community roles. Developments since the review are discussed briefly.

Sociodemographic and health related factors associated with poor mental health in midlife Australian women

OBJECTIVE

To examine associations between poor mental health and sociodemographic, psychosocial and health related variables in midlife Australian women.

METHOD

The random population-based sample comprised 13,961 Australian women aged 45-50 years who participated in the baseline postal survey for the Australian Longitudinal Study on Women's Health, conducted in 1996. The outcome measure, poor mental health status, was measured by the Mental Health Index (MH) of the SF-36.

RESULTS

Sociodemographic factors associated with poor mental health were low educational levels, being unemployed or engaged solely in home duties, and non-English speaking background (European). Health related factors independently associated with poor mental health were having five or more visits to the doctor in the past year, menopausal status (surgical and peri-menopausal), less exercise, and smoking 20 or more cigarettes per day. Among psychosocial variables, low satisfaction with partner or close relationships, low perceived social support outside family, and more life-events over the past 12 months were independently associated.

CONCLUSION

The findings suggest a number of areas in which preventive interventions could be strengthened to improve quality of life among mid-aged women. These include policy changes to promote and support more education and employment opportunities for women before they reach midlife, increase understanding of the link between health risk behaviours and psychological well-being, and provide counselling services to improve women's relational and psychosocial circumstances.

Healthy lifestyles and access to periodic health exams among Brazilian women

Using data from the World Health Survey carried out in Brazil in 2003, this paper has the objective of describing the sociodemographic profile of Brazilian women (age 18-69 years of age) that have adequate health care, not only with respect to health service utilization but also to healthy lifestyles. Sociodemographic variables (age, marital status, race, education level, number of household assets, and occupation), health care variables (periodic gynecologic exam with Papanicolaou, mammography among women aged 40-69 years, body mass index, smoking, alcohol, physical activity, dental care, private health insurance), and self-rated health were analyzed by municipality size strata. Logistic regression models were used to identify the characteristics of women that have adequate health care. Coverage of periodic gynecologic exam with Papanicolaou was 65.0% and mammography coverage was 47.0%. Less than 20.0% of Brazilian women have adequate care, and the most associated factors were: being younger than 40 years old, having higher educational level, having private health insurance and being married. The results indicate the need to develop health promotion policies focused on modifying the risk habits and risk practices to health, and to stimulate preventive periodic health exams.

Concerning women: questionnaire survey of consultations, embarrassment, and views on confidentiality in general practice among women in their teens, thirties and fifties

BACKGROUND

Concern exists that women, and in particular teenagers, do not consult in general practice, particularly for contraception because of embarrassment and concern over confidentiality. The aim of this study was to compare reported consultation rates, embarrassment when consulting, and views on confidentiality of women in three age groups.

METHODS

A postal questionnaire was used to survey women aged 16-19, 36-39 and 56-59 years attending a semi-rural practice in East Devon, UK in December 1999.

RESULTS

Response rates of 57% (teenagers), 79% (women in their thirties) and 89% (women in their fifties) were achieved. In each group over half the respondents had seen a general practitioner (GP) in the previous 3 months. Embarrassment at attending a GP decreased from 38% of teenagers to only 16% of women in their fifties. There was a similar pattern with 78% of teens and 42% of women in their fifties preferring to see a woman doctor for a women's problem and 31% of teens and 18% of women in their fifties expressing a preference for a woman doctor for any problem. Some 97% of women in their thirties and fifties thought a consultation with a GP would be confidential compared with 88% of the teenagers. Only 9% of the teenage group thought the GP might tell their parents about the consultation.

CONCLUSIONS

This study found that teenagers were just as likely as older women to have seen a GP in the preceding 3 months. Embarrassment at attending decreased with age, as did the preference to see a female doctor for both women's and any problems. The majority of women in each age group believed a consultation with a GP, or practice nurse, was confidential.

Gang and multiple rapes during military service: health consequences and health care

OBJECTIVES

We aimed to determine whether there were differences in women veteran's health status and use of health care services by type of rape that occurred during military service.

METHODS

We conducted a national cross-sectional survey of women veterans who served in Vietnam and subsequent eras and were listed in Department of Veterans Affairs comprehensive women's health care registries. We used structured telephone interviews to gather socioeconomic information, violence history, use of outpatient health care services, and health status for a random sample, stratified by region and era of service.

RESULTS

Five hundred forty women completed the interview, 28% of whom reported being raped during military service. Nineteen percent reported a single rape, 5% reported repeated rape (range 2-36), and 5% reported gang rape. Women who reported repeated and gang rapes had significantly impaired physical and emotional health compared with women with a single or no rape (p < or = .05). Repeatedly raped women were more likely to use inpatient and outpatient mental health services (p < or = .05). Gang-rape survivors reported the most severe impairment in physical functioning and general health and demonstrated a trend to seek outpatient medical services.

CONCLUSIONS

Simply asking a woman if she has been raped is not sufficient to detect the level of consequences. More than a decade after military discharge, women who experienced repeated or gang rape during their military service had significant impairment of physical and emotional health compared with women with no or a single rape. The differential health effects associated with severe violence supports the public health importance of sexual violence screening, treatment, and prevention.

The use of complementary and alternative medications by menopausal women in South East Queensland

This study aimed to identify the prevalence and types of complementary and alternative medications (CAMs) used by women during menopause and explore potential associations between CAM use and menopausal symptoms. Analysis was undertaken with 886 randomly selected menopausal women aged 47-67 years who participated in a postal questionnaire on the menopause experience. The prevalence of CAM use was relatively high (82.5%), with nutrition most commonly cited (67%), followed by phytoestrogens (56%), herbal therapies (41%), and CAM medications (25%). Multivariate analysis adjusted for confounders revealed that women who consumed CAM medications were 17-23% more likely to report anxiety (p = .019) or vasomotor symptoms (p = .013). Women who used herbal therapies (p = .009) or phytoestrogens (p = .030) were 13-16% more likely to experience vasomotor symptoms. Women who used nutrition were 18% more likely to experience anxiety (p = .049). These results highlight the importance for health professionals to incorporate CAMs into their practice to better inform menopausal women of their treatment choices.

The Effects of Health and Environment on Exercise-Class Participation in Older, Urban Women

This research investigated the effects of health and environmental factors on the dropout and intermittent nonattendance of an exercise program designed specifically for older, female, primary-care patients living in the inner city. Class-attendance records (n = 21,538) from a cohort 110 women were analyzed. Women who dropped out early had poorer perceived health and were more likely to report pain as an exercise barrier at baseline. Those who lived in a census tract where a larger percentage of workers walk to work were less likely to drop out early. Intermittent nonattendance was associated with adverse weather conditions including heat index above 90 degrees F, wind-chill index below 20 degrees F, overcast sky, and snow. Better attendance was associated with greater atmospheric pressure, as well as lower number of sunlight hours per day. This research highlights the need to better understand environmental barriers when promoting physical activities in older women.

Wages, health benefits, and workers' health

Employer-based health insurance provides the majority of U.S. workers with access to health care and protection against devastating financial losses. Millions of workers, however, do not receive health benefits from their employers, and few sources of affordable coverage exist outside the employer-based system. This study, based on data from the Commonwealth Fund Biennial Health Insurance Survey, finds a deep divide in the U.S. labor force and an urgent need for expanding access to comprehensive and affordable coverage to working Americans and their families. According to the authors, higher-wage workers are more likely than their lower-paid counterparts to have health insurance and health-related benefits, such as paid sick leave, and to use preventive care services. Low-wage workers, meanwhile, are much more likely to forgo needed health care because of cost and to report problems paying medical bills.

Intimate partner violence and sexual assault in Native American communities

Previous studies indicate that Native American women experience the highest rate of violence of any ethnic or racial group in the United States. This article addresses the prevalence of intimate partner violence and sexual assault among Native Americans. We present significant substantive and methodological issues that inform research on violence in the lives of Native Americans, as well as existing interventions. Interventions discussed in this article fall within three major categories including those that are community based, those grounded in the public health and health care systems, and those grounded in federal and national organizations. We provide some examples of interventions from each of these three levels of direct service, including a brief discussion of barriers to service accessibility. We conclude with substantive and methodological recommendations for research and practice.

“Eyes Wide Shut”: Narratives of Women Living with Hepatitis C in Australia

Hepatitis C is the leading notifiable infectious disease in Australia and in the last few years, the number of new diagnoses among young women is beginning to outnumber men. For many, infection with hepatitis C virus (HCV) results in a chronic condition, which, in addition to a range of symptoms, carries with it the stigma attached to injecting drug use. Despite the growing prevalence of HCV, women's health has barely begun to address the gender specific impact of this illness on women. We report the results of a qualitative study of young women's experiences of living with HCV with a specific focus on the meaning of this condition and its impact on their lives. In 1999--2000, twenty-five in-depth interviews were conducted with women between the ages of 18 and 43 years, who were current or past injecting drug users and who had been diagnosed with HCV. One focus group discussion was held with health workers who provide treatment and care to this population. A number of key issues were identified that women believed impacted negatively on their lived experiences of HCV. Of most concern was the meaning of HCV and the social stigma attached. Stigma coupled with the lack of knowledge and awareness among health professionals and the high cost of treatment contributed to women's reluctance to seek support and care. HCV has yet to be taken up by the women's health movement as a key issue, especially for young women and we argue that this trend needs to be reversed.

Empowering Older Women: Strategies to Enhance Their Health and Health Care

Older persons, especially older women, report that often their needs are not met in health care encounters. Lack of active participation by the patient is a major reason for this dissatisfaction. This article reviews research on older women's socialization that discourages them from challenging the status quo in interactions with others. It suggests ways that health care providers can empower female patients: They can encourage active participation during health care encounters, and they can help patients prepare for encounters so they can have their needs met.

Do socioeconomic gradients in women's health widen over time and with age?

A population-based study was conducted to investigate changes over time in women's well-being and health service use by socio-economic status and whether these varied by age. Data from 12,328 mid-age women (aged 45-50 years in 1996) and 10,430 older women (aged 70-75 years) from the Australian Longitudinal Study on Women's Health were analysed. The main outcome measures were changes in the eight dimensions of the Short Form General Health Survey (SF-36) adjusted for baseline scores, lifestyle and behavioural factors; health care utilisation at Survey 2; and rate of deaths (older cohort only). Cross-sectional analyses showed clear socioeconomic differentials in well-being for both cohorts. Differential changes in health across tertiles of socioeconomic status (SES) were more evident in the mid-age cohort than in the older cohort. For the mid-aged women in the low SES tertile, declines in physical functioning (adjusted mean change of -2.4, standard error (SE) 1.1) and general health perceptions (-1.5, SE 1.1) were larger than the high SES group (physical functioning -0.8 SE 1.1, general health perceptions -0.8 SE 1.2). In the older cohort, changes in SF-36 scores over time were similar for all SES groups but women in the high SES group had lower death rates than women in the low SES group (relative risk: 0.79, 95% confidence interval 0.64-0.98). Findings suggest that SES differentials in physical health seem to widen during women's mid-adult years but narrow in older age. Nevertheless, SES remains an important predictor of health, health service use and mortality in older Australian women.

Report from the CDC. Use of Preventive Health Services by Hispanic/Latino Women in Two Urban Communities: Atlanta, Georgia and Miami, Florida, 2000 and 2001

PURPOSE

During the 1990s, a 58% increase in the Hispanic/Latino population, fueled by the century's largest immigration wave and the highest fertility of any group, resulted in Hispanics becoming the largest U. S. minority group. To assess use of preventive services by Hispanics in Atlanta, Georgia, the largest Hispanic new destination, and Miami, Florida, the largest established Hispanic community in the Southeast, survey data were analyzed.

METHODS

Miami-Ft. Lauderdale and Atlanta metropolitan area data from the 2000 National Health Interview Survey (NHIS) and from anonymous surveys conducted at health festivals in Miami and Atlanta in 2001 were analyzed.

RESULTS

Female non-Hispanic white and black NHIS respondents were more likely than Hispanic counterparts to report annual household income >$20,000 (77.3%, 70.8% vs. 67.7%), usual source of healthcare (61.5%, 56.4% vs. 50.2%), or ever having had Pap screening (88.8%, 86.7% vs. 80.7%) or oral contraceptive use (55.7%, 59.7% vs. 33.7%). Miami-Ft. Lauderdale Hispanics were less likely than Atlanta respondents to be monolingual Spanish speakers, to lack usual source of healthcare, or to have less than 12 years of education. Of 295 female health festival respondents, the 160 Miami participants were more likely than Atlanta participants to have health insurance, monthly income >$1000, and prior Pap screening (p < 0.01) but less likely to have used contraception (p = 0.07). Most Hispanics felt they had inadequate healthcare; 15.0% reported being denied healthcare because of inability to pay.

CONCLUSIONS

Low income, uninsured status, and language barriers were associated with lower use of preventive services among Hispanics in these Southeastern communities, particularly Atlanta, a new destination.

Effectiveness of hotline, advocacy, counseling, and shelter services for victims of domestic violence: a statewide evaluation

The authors report the results of an evaluation of services provided by 54 Illinois domestic violence agencies. In collaboration with the University of Illinois at Chicago evaluation team, domestic violence advocates identified services to be evaluated, specified desired outcomes of those services, and participated in developing measures of those outcomes in both English and Spanish. With in the limitations of the study, outcomes were positive in all four program areas: hotline, counseling, advocacy, and shelter. The authors then discuss implications for evaluation of domestic violence programs that maintain victim safety as a guiding principle.

Evaluation of a cervical cancer screening intervention for prison inmates

BACKGROUND

Female prison inmates are underscreened and are at higher risk of cervical cancer. The impact of a nurse-led Pap screening intervention was examined, which included information sessions and Pap testing clinics.

METHOD

Pap screening rates for 650 inmates at the Burnaby Correctional Centre for Women were compared both before and during the 20-week intervention period. These rates were determined by record linkage of Correction Branch inmate records and Cervical Cancer Screening Program patient records. Associations between socio-demographic factors and Pap screening rates were also examined.

RESULTS

A higher proportion of inmates was screened during the intervention period (26.9%) than during the preintervention period (21.0%) (although the difference was not statistically significant (p=0.06)). Very short-stay inmates were less frequently screened in the preceding two years before the intervention. Inmates with no high school education and longer lengths of incarceration were significantly more likely to receive Pap testing during the intervention period as compared to the preintervention period.

CONCLUSION

The nurse-led intervention resulted in a modest improvement in the proportion of inmates receiving Pap screening. Unfortunately, the benefit of the nurse clinician did not reach, to a greater extent, inmates who had not been previously screened or who were inadequately screened. There is need for further work to target this hardest-to-reach group.

Group medical visits for low-income women with chronic disease: a feasibility study

BACKGROUND

Group medical visits (GMVs) have been proposed as a means of providing comprehensive primary care services to patients with chronic disease. We studied the feasibility of implementing a GMV model with low-income women in an innercity clinic setting.

METHODS

The intervention consisted of six GMV sessions cofacilitated by a physician/nurse practitioner team. Participants included 28 women with at least one chronic disease diagnosis (71% Latina). Thematic analysis of open-ended interviews assessed participants' experiences in the GMV. Patient charts and provider logs provided information on health service utilization patterns and provider productivity.

RESULTS

An average of 7 women attended each session, with 16 women attending three or more sessions. In open-ended interviews, the most commonly mentioned positive aspects of the GMV were personalized attention (77%), self-care education (69%), access to medication refills and examinations (69%), and advice from peers (62%). Negative aspects included insufficient personal attention (23%), logistical barriers (8%), and loss of confidentiality (4%). On average, patients required 20 minutes of physician time plus 21 minutes of nurse practitioner time per session. Medical record reviews revealed a significant decrease in urgent care visits (p < 0.05) during the 9 months of the intervention compared with a prior 9-month period.

CONCLUSIONS

In this innercity clinic setting, the GMV model was well tolerated by patients, did not alter provider productivity, and may have encouraged participants to avoid more expensive urgent care services. The results of this pilot study suggest that GMVs represent a cost-effective ambulatory care alternative that is acceptable to low-income women with chronic disease.

The economic toll of intimate partner violence against women in the United States

This study provides estimates of the economic cost of intimate partner violence perpetrated against women in the US, including expenditures for medical care and mental health services, and lost productivity from injury and premature death. The analysis uses national survey data, including the National Violence Against Women Survey and the Medical Expenditure Panel Survey, to estimate costs for 1995. Intimate partner violence against women cost $5.8 billion dollars (95% confidence interval: $3.9 to $7.7 billion) in 1995, including $320 million ($136 to $503 million) for rapes, $4.2 billion ($2.4 to $6.1 billion) for physical assault, $342 million ($235 to $449 million) for stalking, and $893 million ($840 to $946 million) for murders. Updated to 2003 dollars, costs would total over $8.3 billion. Intimate partner violence is costly in the US. The potential savings from efforts to reduce this violence are substantial. More comprehensive data are needed to refine cost estimates and monitor costs over time.