Missed opportunities for human papillomavirus vaccination using Iowa's Immunization Registry Information System

PURPOSE

Adolescent human papillomavirus (HPV) vaccination rates continue to remain lower than other adolescent vaccines, both nationwide and in Iowa. This study examined predictors of missed opportunities for first-dose HPV vaccine administrations in Iowa in order to conduct more targeted outreach and improve adolescent HPV vaccine uptake.

METHODS

A retrospective study was conducted to identify predictors of missed opportunities for first-dose HPV vaccination in Iowa adolescents using Iowa's Immunization Registry Information System. The study population included 154,905 adolescents aged 11-15 years between 2019 and 2022. Missed opportunity for first-dose HPV vaccination was defined as a vaccination encounter where an adolescent received a Tdap and/or MenACWY vaccine but did not receive the first-dose HPV vaccine during the same encounter.

FINDINGS

Over a third of the study population experienced a missed opportunity for HPV vaccination between 2019 and 2022. Missed opportunity for vaccination was most common among individuals living in a rural county (aOR = 1.36), underinsured adolescents (aOR = 1.74), males (aOR = 1.12), teens 13-15 years of age (aOR = 1.76), and White race and non-Hispanic ethnicity.

CONCLUSION

This study builds on previously reported predictors of missed opportunity for HPV vaccination in adolescents. Increased understanding of provider needs and barriers to administering HPV vaccination and further analysis of how the Vaccines for Children Program can play a role in HPV vaccination uptake is necessary to improve HPV vaccination rates among adolescents in Iowa and more specifically in rural communities.

Nitrate exposure from drinking water and dietary sources among Iowa farmers using private wells

Nitrate levels are increasing in water resources across the United States and nitrate ingestion from drinking water has been associated with adverse health risks in epidemiologic studies at levels below the maximum contaminant level (MCL). In contrast, dietary nitrate ingestion has generally been associated with beneficial health effects. Few studies have characterized the contribution of both drinking water and dietary sources to nitrate exposure. The Agricultural Health Study is a prospective cohort of farmers and their spouses in Iowa and North Carolina. In 2018-2019, we assessed nitrate exposure for 47 farmers who used private wells for their drinking water and lived in 8 eastern Iowa counties where groundwater is vulnerable to nitrate contamination. Drinking water and dietary intakes were estimated using the National Cancer Institute Automated Self-Administered 24-Hour Dietary Assessment tool. We measured nitrate in tap water and estimated dietary nitrate from a database of food concentrations. Urinary nitrate was measured in first morning void samples in 2018-19 and in archived samples from 2010 to 2017 (minimum time between samples: 2 years; median: 7 years). We used linear regression to evaluate urinary nitrate concentrations in relation to total nitrate, and drinking water and dietary intakes separately. Overall, dietary nitrate contributed the most to total intake (median: 97 %; interquartile range [IQR]: 57-99 %). Among 15 participants (32 %) whose drinking water nitrate concentrations were at/above the U.S. Environmental Protection Agency MCL (10 mg/L NO3-N), median intake from water was 44 % (IQR: 26-72 %). Total nitrate intake was the strongest predictor of urinary nitrate concentrations (R2 = 0.53). Drinking water explained a similar proportion of the variation in nitrate excretion (R2 = 0.52) as diet (R2 = 0.47). Our findings demonstrate the importance of both dietary and drinking water intakes as determinants of nitrate excretion.

Gradient boosting machine learning model to predict aflatoxins in Iowa corn

Introduction

Aflatoxin (AFL), a secondary metabolite produced from filamentous fungi, contaminates corn, posing significant health and safety hazards for humans and livestock through toxigenic and carcinogenic effects. Corn is widely used as an essential commodity for food, feed, fuel, and export markets; therefore, AFL mitigation is necessary to ensure food and feed safety within the United States (US) and elsewhere in the world. In this case study, an Iowa-centric model was developed to predict AFL contamination using historical corn contamination, meteorological, satellite, and soil property data in the largest corn-producing state in the US.

Methods

We evaluated the performance of AFL prediction with gradient boosting machine (GBM) learning and feature engineering in Iowa corn for two AFL risk thresholds for high contamination events: 20-ppb and 5-ppb. A 90%-10% training-to-testing ratio was utilized in 2010, 2011, 2012, and 2021 (n = 630), with independent validation using the year 2020 (n = 376).

Results

The GBM model had an overall accuracy of 96.77% for AFL with a balanced accuracy of 50.00% for a 20-ppb risk threshold, whereas GBM had an overall accuracy of 90.32% with a balanced accuracy of 64.88% for a 5-ppb threshold. The GBM model had a low power to detect high AFL contamination events, resulting in a low sensitivity rate. Analyses for AFL showed satellite-acquired vegetative index during August significantly improved the prediction of corn contamination at the end of the growing season for both risk thresholds. Prediction of high AFL contamination levels was linked to aflatoxin risk indices (ARI) in May. However, ARI in July was an influential factor for the 5-ppb threshold but not for the 20-ppb threshold. Similarly, latitude was an influential factor for the 20-ppb threshold but not the 5-ppb threshold. Furthermore, soil-saturated hydraulic conductivity (Ksat) influenced both risk thresholds.

Discussion

Developing these AFL prediction models is practical and implementable in commodity grain handling environments to achieve the goal of preventative rather than reactive mitigations. Finding predictors that influence AFL risk annually is an important cost-effective risk tool and, therefore, is a high priority to ensure hazard management and optimal grain utilization to maximize the utility of the nation's corn crop.

Dissolved inorganic and organic carbon export from tile-drained midwestern agricultural systems

While carbon is a critically important natural element cycling through the soil profile of agricultural systems, few studies have examined the flux of dissolved organic carbon (OC) and inorganic carbon (IC) through artificially-drained cropped fields. In this study, we monitored eight tile outlets, nine groundwater wells and the receiving stream during a March to November period in 2018 to quantify subsurface IC and OC flux from tiles and groundwater to a perennial stream from a single cropped field in north-central Iowa. Results showed that carbon export from the field was dominated by IC losses through subsurface drainage tiles that were 20× higher than dissolved OC concentration in tiles, groundwater and in Hardin Creek. IC loads from tiles comprised approximately 96 % of the total carbon export. Detailed soil sampling within the field quantified TC stocks to a 1.2 m depth (246,514 kg/ha), and based on the maximum annual rate of IC loss from the field (553 kg/ha per year), we estimated that approximately 0.23 % of the TC content (0.32 % of the TOC content and 0.70 % of the TIC content) of the shallow soils was lost in a single year. Loss of dissolved carbon from the field is likely offset by reduced tillage and additions of lime. Study results suggest that attention should be given to improved monitoring of aqueous total carbon export from fields for accurate accounting of carbon sequestration performance.

Characterization of Arsenic and Atrazine Contaminations in Drinking Water in Iowa: A Public Health Concern

Arsenic and atrazine are two water contaminants of high public health concern in Iowa. The occurrence of arsenic and atrazine in drinking water from Iowa's private wells and public water systems was investigated over several decades. In this study, the percentages of detection and violation of regulations were compared over region, season, and water source, and factors affecting the detection and concentration of arsenic and atrazine were analyzed using a mixed-effects model. Atrazine contamination in drinking water was found to vary by region, depending on agricultural usage patterns and hydrogeological features. The annual median atrazine levels of all public water systems were below the drinking water standard of 3 ppb in 2001-2014. Around 40% of public water systems contained arsenic at levels > 1 ppb in 2014, with 13.8% containing arsenic at levels of 5-10 ppb and 2.6% exceeding 10 ppb. This unexpected result highlights the ongoing public health threat posed by arsenic in drinking water in Iowa, emphasizing the need for continued monitoring and mitigation efforts to reduce exposure and associated health risks. Additionally, an atrazine metabolite, desethylatrazine, should be monitored to obtain a complete account of atrazine exposure and possible health effects.

Diagnosis of Anaplasma marginale in cattle at the Iowa State University veterinary diagnostic laboratory 2003-2021

Anaplasma marginale is a blood-borne rickettsia-like organism that infects cattle erythrocytes and causes anaplasmosis. This study reviews diagnostic data of all A. marginale diagnostics performed from 2003 to August 2021 in the Iowa State Veterinary Diagnostic Laboratory. Typically, the referring veterinarian's initial tentative diagnosis was based on presenting clinical signs or necropsy findings. Confirmatory testing at the ISU-VDL consisted of light microscopy evaluation of stained blood smears or molecular diagnostic procedures. A total of 94 cases were submitted with tissue samples from deceased animals, of which 79 were from Iowa and 15 were from other states. The most typical gross lesions were widespread yellow adipose tissue and splenomegaly. Typical histopathological lesions included marked bile stasis and hemosiderin-laden macrophages in the liver and spleen, respectively. Starting in 2013, when PCR was implemented to confirm cases of anaplasmosis, 315/1125 (28%) were positive to A. marginale, and 810 were negative, using a cut-off of 35.0 Ct. The average (±SD) of the positive PCR Ct was 19.5 (±6.0), and the first and third quartiles were 14.9 and 23.4. Most cases occurred between August and November, peaking in September, whether from necropsies or positive blood samples by PCR. The most common tick observed in Iowa, Dermacentor variabilis, is likely the main vector for transmission. Further surveys should be conducted to estimate seroprevalence by geographical location, the density of cattle populations, distribution of known vectors according to season, and strains of A. marginale.

The occurrence of bone and joint cancers and their association with rural living and radon exposure in Iowa

Primary bone and joint cancers are rare and understudied, yet these neoplasms are difficult to treat and impact all age groups. To explore the long-term changes in the occurrence of bone and joint cancers, patients diagnosed with these neoplasms between 1975 and 2016 were identified in the Surveillance Epidemiology and End Results of the National Cancer Institute of the USA. The age-adjusted incidence (AAIR) and mortality (AAMR) rates were calculated for three decades and compared to AAIR and AAMR in years 1975-1984. By using the population-based cancer registries of the USA, Iowa was identified as a state with increased cases of bone and joint malignancies. The bone and joint cancer cases in Iowa were correlated with the percentage of rural population, the average farmland size, or the residential radon levels. Results demonstrated that the mean AAIR of bone and joint cancers for US female and male patients (< 50 years of age) increased from 0.57 (95% C.I. 0.55-0.63) and 0.76 (95% C.I. 0.69-0.82) for years 1975-1984 to 0.71 (95% C.I. 0.66-0.76) and 0.94 (95% C.I. 0.87-1.07) for years 2005-2014, respectively. The increase in bone and joint cancer cases in Iowa positively correlated with the percentage rural population (R = 0.222, P < 0.02), and the average farmland size (R = 0.236, P < 0.02) but not the radon levels (R = - 0.038, P < 0.7). The findings revealed that patients younger than 50 years of age and those who resided in rural areas and engaged in farming were more likely to be diagnosed with primary bone and joint cancers.

Paired riparian water table monitoring to quantify hydraulic loading to a saturated buffer

The use of saturated buffers for reducing NO₃-N loads from tile-drained croplands is increasing in the US Midwest and there is a need to develop options for estimating reductions at riparian sites. In this study, we present a paired water table monitoring approach to estimate hydraulic and NO₃-N loading into a saturated buffer in eastern Iowa. One well was located within the saturated buffer (treatment) and a second well was installed in the same section of the riparian buffer but without the saturated buffer (control). Over a season of monitoring, water table depths were remarkably consistent between the two wells but the water table beneath the saturated buffer was consistently 0.22 m higher than the non-saturated buffer control. The increase in water table height increased the amount of water discharged from a 162 m long buffer by 468.2 m³/year and, assuming concentration reduction of 15 mg/l, resulted in a N reduction of approximately 7 kg. Although more work is needed to document this paired monitoring approach elsewhere, the method may hold promise for inexpensively quantifying the performance of conservation practices at landowner-led sites.

Mask Effectiveness for Preventing Secondary Cases of COVID-19, Johnson County, Iowa, USA

In September of 2020, the Iowa Department of Public Health released guidance stating that persons exposed to someone with coronavirus disease (COVID-19) need not quarantine if the case-patient and the contact wore face masks at the time of exposure. This guidance differed from that issued by the Centers for Disease Control and Prevention. To determine the best action, we matched exposure information from COVID-19 case investigations with reported test results and calculated the secondary attack rates (SARs) after masked and unmasked exposures. Mask use by both parties reduced the SAR by half, from 25.6% to 12.5%. Longer exposure duration significantly increased SARs. Masks significantly reduced virus transmission when worn by both the case-patient and the contact, but SARs for each group were higher than anticipated. This finding suggests that quarantine after COVID-19 exposure is beneficial even if parties wore masks.

Salivary Antibodies against Multiple Environmental Pathogens Found in Individuals Recreating at an Iowa Beach

Detecting environmental exposures and mitigating their impacts are growing global public health challenges. Antibody tests show great promise and have emerged as fundamental tools for large-scale exposure studies. Here, we apply, demonstrate and validate the utility of a salivary antibody multiplex immunoassay in measuring antibody prevalence and immunoconversions to six pathogens commonly found in the environment. The study aimed to assess waterborne infections in consenting beachgoers recreating at an Iowa riverine beach by measuring immunoglobulin G (IgG) antibodies against select pathogens in serially collected saliva samples. Results showed that nearly 80% of beachgoers had prior exposures to at least one of the targeted pathogens at the beginning of the study. Most of these exposures were to norovirus GI.1 (59.41%), norovirus GII.4 (58.79%) and Toxoplasma gondii (22.80%) and over half (56.28%) of beachgoers had evidence of previous exposure to multiple pathogens. Of individuals who returned samples for each collection period, 6.11% immunoconverted to one or more pathogens, largely to noroviruses (GI.1: 3.82% and GII.4: 2.29%) and T. gondii (1.53%). Outcomes of this effort illustrate that the multiplex immunoassay presented here serves as an effective tool for evaluating health risks by providing valuable information on the occurrence of known and emerging pathogens in population surveillance studies.

International travel is not a significant risk of exposure for patients at a Midwestern United States travel clinic

The Novel Coronavirus (SARS-CoV-2) was introduced into the United States via travel from Asia and Europe, although the extent of the spread of the disease was limited in the early days of the pandemic. Consequently, international travel may have played a role in the transmission of the disease into Iowa. This study seeks to determine how preferences for international travel changed as novel Coronavirus Disease (COVID-19) spread throughout the world and if any of these returning travelers developed COVID-19 as a result of their trips. This is a retrospective chart review of patients presenting to a travel clinic in Bettendorf, Iowa for pre-travel advice and vaccinations. From October 2019 to March 2020, four hundred twelve (n = 412) patients presented to the clinic. Intended travel to the Western Pacific region (China, Japan, Korea, etc.) decreased dramatically during the study period. All 412 patients were followed in the electronic medical record for the period after their planned travel and only three (3) presented for COVID-19 testing. Two (2) tested positive, and both of these infections were linked to workplace exposures and not due to travel. News of the growing pandemic and travel warnings likely altered patients' travel plans and decreased travel to the most affected regions of the world in the early months of the COVID-19 pandemic. Based on our study, travel was not a significant source of COVID-19 exposure for patients seen at this clinic.

Iowa's Medicaid Healthy Behaviors Program Associated With Reduced Hospital-Based Care But Higher Spending, 2012-17

Health behavior incentive programs are increasingly common in Medicaid programs nationwide. Iowa's Healthy Behaviors Program (HBP) requires Medicaid expansion enrollees to complete an annual wellness exam and health risk assessment or pay monthly premiums to avoid disenrollment. The extent to which the program reduces the use of hospital-based care and lowers health care spending is unknown. Using data for 2012-17 from Medicaid and for 2014-17 from HBP, we evaluated changes in use and spending associated with HBP participation. Compared to nonparticipants, HBP participants were less likely to have an emergency department visit or be hospitalized (by 9.6 percentage points and 2.8 percentage points, respectively) but had higher total health care spending ($1,594). Meanwhile, Iowa's Medicaid expansion was associated with increased use and spending independent of HBP participation-that is, applying to both participants and nonparticipants. Overall, our findings suggest that the HBP was associated with substantial reductions in hospital-based care but increased health care spending.

Use of Advance Care Planning Billing Codes in a Tertiary Care Center Setting

INTRODUCTION

The Centers for Medicare and Medicaid Services released the final payment rules for reimbursement of advance care planning (ACP) effective January 2016. In its first year, 23,000 providers nationwide submitted 624,000 claims using the Current Procedural Terminology codes 99497 and 99498. The objectives of our study were to 1) assess the frequency of ACP codes used at a single academic tertiary care center in Iowa, 2) determine when and by whom the codes were used, and 3) summarize ACP clinical notes.

METHODS

Using the electronic medical record data warehouse from a single tertiary teaching hospital and affiliated clinics, date of service, department where service was provided, provider name and type, patient medical record number, date of birth, and gender linked to the ACP codes 99497 and 99498 were collected. The content of ACP clinical notes were reviewed and summarized. Study period was from January 1, 2016 through September 19, 2018.

RESULTS

During the 33 months, code 99497 was used 17 times and code 99498 was never used. Code 99497 was successfully reimbursed 4 times.

DISCUSSION

Charges were not reimbursed if the ACP visits did not meet the minimum time requirement or were conducted by an individual not considered a qualified health care professional per Medicare rules.

CONCLUSION

ACP codes 99497 and 99498 were very rarely used at this tertiary care center during the initial 33-months after the Medicare rules went into effect. Interventions are needed to promote the use of ACP codes, so the time spent in important ACP discussions are properly compensated.

Change in Australian Vitamin A Intakes over Time

BACKGROUND

The mean intake of vitamin A of Australians aged 2 y and older was 300 µg retinol equivalents lower in the 2011-2012 national nutrition survey than in 1995 and decreases preponderated in adults rather than young children.

OBJECTIVE

This aim of this study was to identify the foods associated with this change and to examine how the method used to adjust for within-person variability affects the estimated prevalence of inadequate intakes in both surveys.

METHODS

Foods contributing to vitamin A intake were calculated from the first day of data. The prevalence of inadequate intakes was calculated using a 2-d average, the Iowa State University method, and the National Cancer Institute (NCI) method and either taken from the published reports or calculated using Food Standards Australia New Zealand's in-house software.

RESULTS

In adults, lower consumption of liver, yellow fat spreads, milk products, and carrots and similar root vegetables accounted for most of the change in intake. Vitamin A intake data were less right-skewed in 2011-2012 than in 1995. The prevalence of inadequate vitamin A intake depended on the adjustment method chosen: for example, in 2011-2012 it ranged between 3% and 55% in men aged 19-30 y. The NCI method prevalence (21% for this group) is taken as the preferred estimate of inadequacy because the method adjusts around the mean and accounts for several other sources of variance. However, the NCI method could not be used to analyze the 1995 survey.

CONCLUSIONS

The lower vitamin A intake in Australia was related to changes in retinol intake rather than carotenoid intake and to lower consumption of several different types of food. The estimated prevalence of inadequate intake depends on the statistical method chosen for analysis. A direct measure of vitamin A status is needed to allow conclusions about the implications of the decreasing intake of this vitamin.

Management of initial carious lesions: Iowa survey

BACKGROUND

The authors explore Iowa dentists' agreement with the International Caries Classification and Management System (ICCMS) in the nonsurgical management of initial carious lesions in patients at low, moderate, and high caries risk and identify factors related to their agreement.

METHODS

Electronic surveys were mailed to 916 actively practicing dentists who are alumni of the College of Dentistry at The University of Iowa. Questions included clinical scenarios that used text, clinical photographs, and radiographic images of initial carious lesions. Dentists were asked what type of treatment they would recommend. Treatment options included no treatment, nonsurgical treatment, or surgical treatment. Logistic regression analyses were used to assess associations among agreement with ICCMS, characteristics of the dentist's practice, and patients' caries risk level.

RESULTS

A total of 138 Iowa dentists responded to the survey. Agreement with ICCMS regarding nonsurgical management of initial carious lesions for patients at low, moderate, and high risk levels were 73%, 59%, and 51% respectively. Compared with their counterparts, dentists who agreed with the recommendations for nonsurgical treatment were more likely to dry the teeth during caries detection (95% confidence interval [CI], 1.02 to 12.67, P = .0468), use magnification (95% CI, 1.16 to 7.17, P = .0225) for caries detection, have graduated less than 20 years ago (P = .0024), practice in public health settings (P = .0089), and perform a caries risk assessment (95% CI, 1.10 to 4.29, P = .0262).

CONCLUSIONS

Dentists who dry teeth, use magnification for caries detection, graduated in the past 20 years, practice in a public health setting, and perform a caries risk assessment were significantly more likely to make decisions that were consistent with the guidelines of the ICCMS.

PRACTICAL IMPLICATIONS

Knowledge of evidence-based options personalized for a patient's risk status is essential for applying the best management of initial caries lesions.

Quantifying the contribution of tile drainage to basin-scale water yield using analytical and numerical models

The Des Moines Lobe (DML) of north-central Iowa has been artificially drained by subsurface drains and surface ditches to provide some of the most productive agricultural land in the world. Herein we report on the use of end-member mixing analysis (EMMA) models and the numerical model Soil and Water Assessment Tool (SWAT) to quantify the contribution of tile drainage to basin-scale water yields at various scales within the 2370 km² Boone River watershed (BRW), a subbasin within the Des Moines River watershed. EMMA and SWAT methods suggested that tile drainage provided approximately 46 to 54% of annual discharge in the Boone River and during the March to June period, accounted for a majority of flow in the river. In the BRW subbasin of Lyons Creek, approximately 66% of the annual flow was sourced from tile drainage. Within the DML region, tile drainage contributes to basin-scale water yields at scales ranging from 40 to 16,000 km², with downstream effects diminishing with increasing watershed size. Developing a better understanding of water sources contributing to river discharge is needed if mitigation and control strategies are going to be successfully targeted to reduce downstream nutrient export.

Soil sedimentation and quality within the roadside ditches of an agricultural watershed

Roadside ditches are an integral component to the >6.3 million km of roadsides in the U.S. and act as drainageways for millions of hectares of watershed runoff. Our study of six roadside ditches in Lime Creek watershed characterized soil nutrients and heavy metal patterns as well as quantified the physical and hydrological properties of ditch soils. At all ditch sites, we identified significant sedimentation of silt-sized particles, total nitrogen, and soil carbon in shallow roadside ditch soils. A post-settlement surface soil horizon significantly higher in silt content was observed compared to the underlying subsoil and parent material. Although accumulation of several heavy metals was measured in ditch soils, significant variability was not observed within the ditch environment. Most of the heavy metal concentrations were found to be either similar to or lower than state-wide averages. Higher levels of calcium near the roads were likely due to annual use of road deicers. Overall, we estimated that 42 Mg/ha of total carbon and 5 Mg/ha of total nitrogen are being stored in agricultural ditch soils, which is similar to that of surrounding agricultural land in terms of total carbon storage, but much higher than estimates of total nitrogen storage. Our study of six roadside ditches in an eastern Iowa watershed documented the soil chemistry, morphology, and sediment accumulation that occurred since ditch construction. Further research is needed to develop a better understanding of how the soil and water conditions in the ditches related to the watershed areas that feed them.

Hydrograph separation of subsurface tile discharge

Baseflow is an important component of streamflow and watershed hydrologic budgets, yet quantifying the baseflow fraction of tile drainage has rarely been reported. In this study, we used two common hydrograph separation methods (local minimum method, recursive digital filter) to separate the discharge hydrographs from three drainage district tiles located in Iowa. Based on data collected from 2009 to 2013, annual baseflow ranged from 116 to 162 mm and comprised approximately 60% of the annual discharge. Baseflow was greatest during June (average of 34% of annual baseflow) and the March through August period produced 86% of the total annual baseflow. We found that the two methods of hydrograph separation produced similar results but the digital filter method was less erratic in estimating baseflow fraction. Study results can be used to better quantify hydrologic pathways in tiled landscapes and improve the design, implementation, and evaluation of nutrient reduction strategies.

Subsurface nutrient processing capacity in agricultural roadside ditches

Roadside ditches located throughout urban and rural landscapes are integral components of watershed-scale hydrologic processes but their capacity to reduce nutrients in the subsurface environment has not been investigated. In this study, vegetation, soil and groundwater conditions were characterized in six roadside ditches in the 66 km² Lime Creek watershed in eastern Iowa. Shallow water table wells were installed at 17 locations in six transects and sampled monthly in 2017 to evaluate spatial and temporal patterns. Vegetation characteristics were surprisingly diverse but was not found to be a significant factor in water quality patterns. Groundwater NO₃-N concentrations were <1 mg/L in wells at two transects and were observed to decrease from upgradient to downgradient positions at four locations (average 60% reduction). Water table levels were very shallow (<0.3 m) at nearly all sites, and the loamy and organic rich ditch soils appeared sufficiently anaerobic for subsurface processing of NO₃-N via denitrification to occur. Groundwater dissolved reactive phosphorus concentrations did not vary systematically among the sites whereas two of the roadside ditches had Cl concentrations indicative of road salt encroachment. With estimated NO₃-N reductions equivalent to typical wetland N reductions we recommend consideration of roadside ditches to serve as "linear wetlands" for watershed-scale treatment of nonpoint source pollution.

Iowa Stream Nitrate, Discharge and Precipitation: 30-Year Perspective

We evaluated Iowa Department of Natural Resources nitrate (NO₃-N) and US Geological Survey hydrological data from 1987 to 2016 in nine agricultural watersheds to assess how transport of this pollutant has changed in the US state of Iowa. When the first 15 years of the 30-year water-quality record is compared to the second 15 years (1987-2001 and 2002-2016), three different metrics used to quantify NO₃-N transport all indicate levels of this pollutant are increasing. Yield of NO₃-N (kg ha^-1) averaged 18% higher in the second 15 years, while flow-weighted average concentrations (mg L^-1) were 12% higher. We also introduced the new metric of NO₃-N yield (g ha^-1) per mm precipitation to assess differences between years and watersheds, which averaged 21 g NO₃-N ha^-1 per 1 mm of precipitation across all watersheds and was 13% higher during the second half of the record. These increases of NO₃-N occurred within a backdrop of increasing wetness across Iowa, with precipitation and discharge levels 8 and 16% higher in the last half of the record, indicating how NO₃-N transport is amplified by increasing precipitation levels. The implications of this are that in future climate scenarios where rainfall is more abundant, detaining water and increasing evapotranspiration within the cropping system will be necessary to control NO₃-N losses. Land use changes that include use of cover crops, living mulches, and perennial plants should be expanded to improve water quality and affect the water balance within agricultural basins.

Whole-Genome Analysis of Recurrent Staphylococcus aureus t571/ST398 Infection in Farmer, Iowa, USA

Staphylococcus aureus strain sequence type (ST) 398 has emerged during the last decade, largely among persons who have contact with swine or other livestock. Although colonization with ST398 is common in livestock workers, infections are not frequently documented. We report recurrent ST398-IIa infection in an Iowa farmer in contact with swine and cattle.

Ligictaluridus michaelalicea n. sp. (Monogenea: Dactylogyridae) from flathead catfish (Pylodictis olivaris) in the upper Mississippi River, including remarks on taxonomy influencing monogenean treatment regulation in the United States

Ligictaluridus michaelalicea n. sp. (Monogenea: Dactylogyridae, Ancyrocephalinae) is described from the gills of Pylodictis olivaris (Siluriformes: Ictaluridae) from Wisconsin and Iowa portions of the upper Mississippi River. Diagnostic features include a relatively large, strongly curved tubular cirrus with minor terminal flare; an accessory piece with a prominent basal lobe and a simple, thick terminal limb featuring a thin lateral flange and blunt distal tip devoid of recurved hooks. The sinistral vagina, two prostatic reservoirs, and a terminal seminal vesicle of the vas deferens are prominent. The anchors, ventral and dorsal bars, and hooks are similar in overall form to those of other members of the genus. The description includes sequence data for the 18S rRNA gene, which aligned most closely with species of ancyrocephaline monogeneans, with the highest similarity being with Ligictaluridus pricei (Mueller, 1936). Other monogenean species identified from the flathead catfish examined included L. pricei and Ligictaluridus mirabilis (Mueller, 1937). L. michaelalicea n. sp. is the fourth species to be described from P. olivaris within its natural range in central and eastern North America. Implications resulting from taxonomic name changes, including species of Ligictaluridus, and United States Food and Drug Administration treatment regulations are discussed. An updated key to species of the genus Ligictaluridus is presented.

Highly Pathogenic Avian Influenza A(H7N9) Virus, Tennessee, USA, March 2017

In March 2017, highly pathogenic avian influenza A(H7N9) was detected at 2 poultry farms in Tennessee, USA. Surveillance data and genetic analyses indicated multiple introductions of low pathogenicity avian influenza virus before mutation to high pathogenicity and interfarm transmission. Poultry surveillance should continue because low pathogenicity viruses circulate and spill over into commercial poultry.

Low-level arsenic exposure from drinking water is associated with prostate cancer in Iowa

Inorganic arsenic is a toxic naturally occurring element in soil and water in many regions of the US including the Midwest. Prostate cancer is the second most common type of cancer in men in Iowa, surpassed only by non-melanotic skin cancer. Epidemiology studies have evaluated arsenic exposure from drinking water and prostate cancer, but most have focused on high-level exposures outside the US. As drinking water from groundwater sources is a major source of arsenic exposure, we conducted an ecologic study to evaluate prostate cancer and arsenic in drinking water from public water sources and private wells in Iowa, where exposure levels are low, but duration of exposure can be long. Arsenic data from public water systems were obtained from the Iowa Safe Drinking Water Information System for the years 1994-2003 and for private wells from two Iowa Well Water Studies, the Iowa Community Private Well Study (ICPWS, 2002-2003) and Iowa Statewide Rural Well Water Survey Phase 2 (SWIRL2, 2006-2008) that provided data for 87 Iowa counties. Prostate cancer incidence data from 2009 to 2013 for Iowa were obtained from Surveillance, Epidemiology and End Results' SEER*Stat software. County averages of water arsenic levels varied from 1.08 to 18.6 ppb, with three counties above the current 10 ppb limit. Based on the tertiles of arsenic levels, counties were divided into three groups: low (1.08-2.06 ppb), medium (2.07-2.98 ppb), and high (2.99-18.6 ppb). Spatial Poisson regression modeling was conducted to estimate the risk ratios (RR) of prostate cancer by tertiles of arsenic level at a county level, adjusted for demographic and risk factors. The RR of prostate cancer were 1.23 (95% CI, 1.16-1.30) and 1.28 (95% CI, 1.21-1.35) in the medium and high groups, respectively, compared to the low group after adjusting for risk factors. The RR increased to 1.36 (95% CI, 1.28-1.45) in the high group when analyses were restricted to aggressive prostate cancers (Gleason score ≥ 7). This study shows a significant dose-dependent association between low-level arsenic exposure and prostate cancer, and if this result is replicated in future individual-level studies, may suggest that 10 ppb is not protective for human health.

Public-Private Partnerships Working Beyond Scale Challenges toward Water Quality Improvements from Private Lands

In recognition that Iowa agriculture must maintain long-term production of food, fiber, clean water, healthy soil, and robust rural economies, Iowa recently devised a nutrient reduction strategy to set objectives for water quality improvements. To demonstrate how watershed programs and farmers can reduce nutrient and sediment pollution in Iowa waters, the Iowa Water Quality Initiative selected the Boone River Watershed Nutrient Management Initiative as one of eight demonstration projects. For over a decade, diverse public, private, and non-profit partner organizations have worked in the Boone River Watershed to engage farmers in water quality management efforts. To evaluate social dynamics in the Boone River Watershed and provide partners with actionable recommendations, we conducted and analyzed semi-structured interviews with 33 program leaders, farmers, and local agronomists. We triangulated primary interview data with formal analysis of Boone River Watershed documents such as grant applications, progress reports, and outreach materials. Our evaluation suggests that while multi-stakeholder collaboration has enabled partners to overcome many of the traditional barriers to watershed programming, scale mismatches caused by external socio-economic and ecological forces still present substantial obstacles to programmatic resilience. Public funding restrictions and timeframes, for example, often cause interruptions to adaptive management of water quality monitoring and farmer engagement. We present our findings within a resilience framework to demonstrate how multi-stakeholder collaboration can help sustain adaptive watershed programs to improve socio-ecological function in agricultural watersheds such as the Boone River Watershed.

Prospective study of the dietary inflammatory index and risk of breast cancer in postmenopausal women

SCOPE

Diet in relation to breast cancer etiology has been studied widely, but results have remained inconsistent. Various dietary components including fruits, vegetables, and meat have been implicated through their effects on inflammation. Using data from the Iowa Women's Health Study we examine prospectively the association between the dietary inflammatory index (DII) and breast cancer incidence.

METHODS AND RESULTS

DII scores were computed based on baseline dietary intake assessed by a validated 121-item food frequency questionnaire in a cohort of 34 700 women, aged 55-69 years at recruitment in 1986 and followed for incident breast cancer. During the 25-year follow-up period (1986-2011), 2910 incident breast cancer cases were identified. We used Cox proportional hazards regression to estimate multivariable hazard ratios (HRs) and 95% confidence intervals (CI). We found positive associations between DII scores and breast cancer risk (HR for DII_tertiles : T₃ vs T₁ = 1.11; 95% CI: 1.00, 1.22), with stronger associations in obese women (HR for DII_continuous : 1.05 per unit increase in DII; 95% CI: 1.02, 1.12; HR for DII_tertiles : T₃ vs T₁ = 1.35; 95% CI: 1.10, 1.66, p-value for interaction = 0.02).

CONCLUSION

A proinflammatory diet, as indicated by higher DII scores, appears to increase the risk of developing breast cancer, especially in obese postmenopausal women.

Pigs in Space: Determining the Environmental Justice Landscape of Swine Concentrated Animal Feeding Operations (CAFOs) in Iowa

Given the primacy of Iowa in pork production for the U.S. and global markets, we sought to understand if the same relationship with traditional environmental justice (EJ) variables such as low income and minority populations observed in other concentrated animal feeding operation (CAFO) studies exists in the relationship with swine CAFO densities in Iowa. We examined the potential for spatial clustering of swine CAFOs in certain parts of the state and used spatial regression techniques to determine the relationships of high swine concentrations to these EJ variables. We found that while swine CAFOs do cluster in certain regions and watersheds of Iowa, these high densities of swine are not associated with traditional EJ populations of low income and minority race/ethnicity. Instead, the potential for environmental injustice in the negative impacts of intensive swine production require a more complex appraisal. The clustering of swine production in watersheds, the presence of antibiotics used in swine production in public waterways, the clustering of manure spills, and other findings suggest that a more literal and figurative “downstream” approach is necessary. We document the presence and location of antibiotics used in animal production in the public waterways of the state. At the same time, we suggest a more “upstream” understanding of the structural, political and economic factors that create an environmentally unjust landscape of swine production in Iowa and the Upper Midwest is also crucial. Finally, we highlight the important role of publicly accessible and high quality data in the analysis of these upstream and downstream EJ questions.

Iowa Wavering on Medicaid: From Expansion to Modernization

Iowa is one of six states to expand Medicaid through section 1115 waivers. Iowa's alternative approach to Medicaid expansion, known as the Iowa Health and Wellness Plan, was the result of a bipartisan compromise, motivated by the pending expiration of a preexisting section 1115 waiver that served sixty-five thousand Iowans. The Iowa Health and Wellness Plan emphasizes personal responsibility and private involvement. Key features include beneficiary premiums, incentives for healthy behaviors, and premium assistance for some beneficiaries to purchase insurance in the health insurance marketplace. However, Iowa has struggled to implement its expansion as initially envisioned, due largely to the lack of private insurers willing and able to insure new Medicaid enrollees in the marketplace. In 2016 Iowa will dramatically increase the role of managed care in Medicaid, with the vast majority of beneficiaries receiving almost all Medicaid services through a capitated managed care organization. This article highlights the local factors driving expansion, the interplay of the state and federal political landscape, the challenges of providing consumer choice within Iowa's marketplace, and the future of Iowa's Medicaid program under managed care.

Left Hemispheric Imbalance and Reward Mechanisms Affect Gambling Behavior: The Contribution of the Metacognition and Cortical Brain Oscillations

The present research used the Iowa Gambling Task to test the effect of the reward-sensitivity Behavioral Activation System-Reward (BAS-Reward) construct on the ability to distinguish between high- and low-risk decisions. To elucidate the individual differences that influence the decisional processes, making the strategies more or less advantageous, we considered the impact of the BAS motivational system and the frontal left and right cortical activity on subjects' decisions. More specifically, the lateralization effect, which is related to the increased activation of the left (BAS-Reward-related) hemisphere, was explored by using frequency band analysis. Specifically, behavioral responses (gain/loss options), metacognition, and delta, theta, alpha, and beta band modulation (asymmetry index) were considered. Thirty subjects were divided into high-BAS and low-BAS groups. In comparison with low-BAS, the high-BAS group showed an increased tendency to opt in favor of the immediate reward (losing strategy) instead of the long-term option (winning strategy), and members of this group were more impaired in metacognitive monitoring of their strategies and showed an increased left hemisphere activation when they responded to losing choices. A "reward bias" effect was hypothesized to act for high BAS, based on a left-hemisphere hyperactivation.

Making the Blue Zones: Neoliberalism and nudges in public health promotion

This paper evaluates the ideological and political origins of a place-based and commercial health promotion effort, the Blue Zones Project (BZP), launched in Iowa in 2011. Through critical discourse analysis, I argue that the BZP does reflect a neoliberalization of public health, but as an "actually existing neoliberalism" it emerges from a specific policy context, including dramatic health sector policy changes due to the national Affordable Care Act, also known as Obamacare; a media discourse of health crisis for an aging Midwestern population; and an effort to refashion Iowa cities as sites of healthy and active living, to retain and attract a creative class of young entrepreneurs. The BZP employs many well-known mechanisms of neoliberal governance: the public-private partnership; competition among communities for "public" funds; promotion of an apolitical discourse on individual responsibility and ownership of health; decentralizing governance to the "community" level; and marketing, branding, and corporate sponsorship of public projects. The BZP exemplifies the process of "neoliberal governmentality," by which individuals learn to govern themselves and their "life projects" in line with a market-based rationality. However, with its emphasis on "nudging" individuals towards healthy behaviors through small changes in the local environment, the BZP reflects the rise of "libertarian paternalism," a variant of neoliberalism, as a dominant ideology underlying contemporary health promotion efforts.

Implementation of the Affordable Care Act and rural health clinic capacity in Iowa

OBJECTIVE

To evaluate the capacity of rural health clinics (RHCs) in Iowa as the Affordable Care Act (ACA) is implemented.

METHODS

We developed and fielded an online survey among the 142 RHCs in Iowa.

RESULTS

The survey response rate was 19% and this exceeds the response rate of previously published RHC studies. Responding RHCs report struggling to provide dental care and mental health services, and indicate a high degree of recruiting difficulty for physicians (80%), physician assistants, and nurse practitioners (both 50%), with referrals to specialists being common. Nearly 60% of RHC respondents anticipate an increase in the size of their patient population because of the ACA, with 14.8% expecting a substantial increase. Respondents indicated a lack of preparedness for participating in a value-based health care delivery system. While nearly all RHC respondents (90.4%) report knowing what steps they need to take to respond to the challenges health reform may present, only 19% agree that they have the human, financial, and material resources necessary to respond to those challenges.

CONCLUSION

RHCs have limited capacity to respond to the opportunities and challenges of the ACA, and need additional resources and incentives to thrive in a reformed health care delivery system.

Is whole grain intake associated with reduced total and cause-specific death rates in older women? The Iowa Women's Health Study

OBJECTIVES

This study sought to determine whether nutrient-rich whole grains reduce mortality risk.

METHODS

The study included 38,740 Iowa women, aged 55 to 69 years. A food frequency questionnaire was used to obtain data on grain intake.

RESULTS

Median whole grain intake quintiles ranged from a median of 0.2 to more than 3 servings per day. Women with higher intakes had healthier lifestyles and less baseline disease. The total death rate decreased in increasing quintiles, and the pattern repeated for cancer, cardiovascular disease, and other causes combined. Adjusted for lifestyle and baseline disease, the relative hazard rate ratio for total death was about 0.85 in daily consumers of whole grain. Findings persisted in strata of baseline healthy and diseased and were not explained by dietary fiber. Rates of total mortality, but not cardiovascular disease mortality, were higher among frequent consumers of refined grain.

CONCLUSIONS

Total mortality risk was inversely associated with whole grain intake and positively associated with refined grain intake. Refined grains contributed more than 20% of energy intake, and whole grains contributed 1%. Substitution of whole for refined grain may reduce chronic disease risk in the United States.

Relation of calcium, vitamin D, and dairy food intake to ischemic heart disease mortality among postmenopausal women

To investigate whether greater intakes of calcium, vitamin D, or milk products may protect against ischemic heart disease mortality, the authors analyzed data from a prospective cohort study of 34,486 postmenopausal Iowa women 55-69 years old and without a history of ischemic heart disease who completed a dietary questionnaire in 1986. Through 1994, 387 deaths due to ischemic heart disease were documented (International Classification of Diseases, Ninth Revision, codes 410-414, 429.2). The multivariate-adjusted relative risks for the highest versus the lowest quartiles of total calcium, vitamin D, and milk product intakes were as follows: 0.67 (95% confidence interval (CI) 0.47-0.94; p for trend = 0.09) for calcium, 1.41 (95% CI 0.93-2.15; p for trend = 0.12) for vitamin D, and 0.94 (95% CI 0.66-1.35; p for trend = 0.68) for milk products. The relative risk was 0.63 (95% CI 0.40-0.98) for high dietary calcium but no supplemental calcium intake and 0.66 (95% CI 0.36-1.23) for high supplemental calcium but low dietary calcium intake. These results suggest that a higher intake of calcium, but not of vitamin D or milk products, is associated with reduced ischemic heart disease mortality in postmenopausal women, and reduced risk may be achievable whether the higher intake of calcium is attained by diet, supplements, or both.

Iowa trial court blocks parental notification law

The US District Court for the Southern District of Iowa issued a preliminary injunction on January 22 that prohibits enforcement of that state's parental notification requirement for young women seeking abortions. Under the law, which was passed by the Iowa legislature in March 1996, one parent of a woman under the age of 18 must be notified at least 48 hours before the procedure (see RFN V/6). Alternatively, the young woman may seek a court waiver of the mandate. Judge Ronald Longstaff found that the women's health care providers challenging the law were likely to prevail in their claim that the statute presents an unconstitutional obstacle to young women's right to choose abortion. Affirming findings made in a temporary restraining order that prevented the law from taking effect earlier in the month, Judge Longstaff held that the law would put doctors who provide emergency abortions to young women at risk of liability, a possibility that could discourage physicians from providing abortion services (see RFN VI/1). The court also found that the judicial bypass laid out in the statute failed to sufficiently protect a young woman's confidentiality or guarantee an expeditious procedure. The plaintiffs in Planned Parenthood of Greater Iowa vs. Miller are represented by Dara Klassel and Roger Evans of the Planned Parenthood Federation of America, CRLP's Priscilla Smith and Michael Erdos, Mark Lambert of Planned Parenthood of Greater Iowa, and Randall Wilson of the Iowa Civil Liberties Union.

District court finds proposed Iowa women's health facility does not need state approval

On October 18, the US District Court for the Southern District of Iowa ordered the Iowa Department of Health to withdraw its demand that Planned Parenthood of Greater Iowa obtain a "certificate of need" in order to open a new facility in Davenport. Judge Charles R. Wolle found that state officials had deliberately misused the certificate of need requirement--a policy originally created to allow communities to influence health care standards at local facilities and prevent duplication of medical services--to block the clinic, which far from providing duplicative services would become the only provider of abortions in the Quad Cities. For at least 10 years, no family planning facility in Iowa has been required to obtain a certificate of need, in large part because the review standards are generally regarded as obsolete. The application process would have required Planned Parenthood to publicly disclose its sources of funding, identify the intended site of the facility, and pay a substantial fee; it would also have involved a public hearing at which members of the community could object to the clinic. The court concluded that state officials could not justify applying the requirements to a facility providing abortions when it had routinely failed to apply them to other clinics that offer the same services but do not provide abortions. Judge Wolle further ruled that the state's order for a certificate of need imposes a substantial obstacle to access to abortion that is unjustified by any government interest--and therefore unconstitutional under the standards established by the US Supreme Court in Planned Parenthood vs. Casey. Planned Parenthood Federation of America is representing the plaintiffs in Planned Parenthood of Greater Iowa vs. Atchison.

Sphenoid wing meningioma progression after placement of a subcutaneous progesterone agonist contraceptive implant

A causal relationship between sex steroids and meningioma proliferation has long been suspected. We report a case of the clinical progression of a sphenoid wing meningioma after the placement of Norplant, a subcutaneous contraceptive implant containing levonorgestrel, a progesterone agonist. Although not proof of causation, this observation lends further credence to the importance of progesterone receptors in the growth and possible treatment of meningiomas.

A benefit-cost analysis of family planning services in Iowa

An analysis of publicly funded family planning services in Iowa was undertaken to provide tangible estimates based on local data of the value of these services in averting unplanned and unwanted births to women who voluntarily use them. The study reports methods that can be applied by other states in evaluating their own family planning programs. Benefits were measured as the cost savings in public expenditures avoided by providing family planning services to low- and marginal-income women. Iowa data for AFDC, food stamps, and Medicaid payments were used to calculate benefits. The total benefit savings were adjusted to reflect the impact of family planning services on preventing births. The adjusted savings were accrued over one-year and five-year time frames and for four age groups (14-19, 20-29, 30-34, and 35-44). In the base year, the cost of providing family planning services in Iowa to the more than 56,000 women who used them was $3.1 million, or $59 per user. Results showed that the benefits of family planning services were highest for teenagers who would become eligible for public assistance programs upon the birth of a child.

Attitudes toward sex, arousal, and the retention of contraceptive information

Previous research has suggested that women with a negative emotional orientation toward sexuality (i.e., erotophobia) have difficulty learning and retaining sexually relevant material such as contraceptive information. It has been hypothesized that these women become aroused by this material and that this arousal interferes with their ability to learn it. The importance of this issue led us to conduct the current study. Erotophobic and erotophilic women viewed presentations about contraception while their physiological responses were being monitored. In addition, they were tested on the information contained in the presentation before, immediately after, and again 4-6 weeks after the presentation. The results indicated that the erotophobic women knew less contraceptive information before the presentation and were more aroused by the presentation. This arousal, however, did not interfere with retention of the material. These results are discussed in terms of individual differences in reactions to sexual material and the ability to learn, retain, and use contraceptive information.

The evaluation of the data collection process for a multicenter, population-based, case-control design

This report details the methods the authors used to conduct the Cancer and Steroid Hormone Study, a multicenter, population-based, case-control study of oral contraceptive use in relation to breast, endometrial, and ovarian cancer diagnosed during 1980-1982. The authors have documented their methods and rationale, and the results of their data collection efforts as a practical guide for the planning and conduct of large case-control studies. They observed the following: 1) the Surveillance, Epidemiology, and End Results program is a useful epidemiologic resource for identifying cases from which to evaluate risk factors for cancer in the United States; 2) random digit dialing is an effective and efficient method for screening for eligible controls for a population-based study; 3) with the cooperation of community pathologists, histologic specimen slides can be retrieved and reviewed for diagnostic confirmation and histologic subclassification of cancer for greater than 95% of the cases interviewed; and 4) data reported during personal interviews of study participants can be validated by reviewing medical records for more than 75% of study participants who reported medical events that occurred during the 10 years before the beginning of the study.

United States. Iowa. Supreme Court. Witcraft v. Sundstrand Health and Disability Group Benefit, 16 March 1988

The plaintiffs sought insurance reimbursements for sperm treatment and artificial insemination. The Supreme Court of Iowa ruled that the words illness, sickness, and disease are used synonymously in health insurance contracts and that the treatments for infertility were treatments of an illness, or morbid condition of the body, that is, a deviation from the healthy or normal condition of any functions or tissues of the body.

Cigarette smoking and the risk of epithelial ovarian cancer

Cigarette smoking may affect each of the currently proposed mechanisms of ovarian carcinogenesis. Whether cigarette smoking has any effect on the development of ovarian cancer has not been adequately evaluated. To study this issue, the authors examined data from the Cancer and Steroid Hormone Study, a multicenter, case-control study of gynecologic cancers conducted between December 1, 1980, and December 31, 1982, in eight geographic areas of the United States. This analysis utilized data on 494 women with newly diagnosed epithelial ovarian cancer and 4,238 population-based control women 20-54 years of age. There was no association of epithelial ovarian cancer with dose of cigarette smoking, age smoking started, time since smoking started, or time since smoking last occurred. Simultaneous adjustment for age, parity, history of oral contraceptive use, and other potentially confounding factors did not alter these results.

Correlates of urban mortality: a social area analysis

A method of social area analysis developed by Shevky and Bell is used to analyze mortality among the census tracts of Des Moines, Iowa. "Social rank, urbanization, and segregation indices as well as age-standardized death rates were calculated for each census tract. All variables were treated as continuous, and correlation and regression procedures were used to analyze the data. The findings were consistent with those of previous studies and all relationships were as expected. Regression analysis revealed that segregation contributed little to the explanation of variation in age-standardized death rates, suggesting that segregation is not an important determinant of life styles affecting mortality independent of social rank. The results were interpreted in terms of social class differences in accessibility to medical assistance and assumption of the sick role."

Unplanned pregnancies in a midwestern community

Despite widespread birth control availability and increasing emphasis on sex education, a large proportion of childbearing continues to be unplanned. Using an anonymous questionnaire, unplanned pregnancies were studied in Cedar Rapids, Iowa. Of 1,002 women who completed questionnaires, 56 percent had had one or more unplanned pregnancies, and 44 percent of all pregnancies were found to be unplanned. This study confirms the findings of other studies which have shown a similar proportion of unplanned pregnancies. More unplanned pregnancies occur in the younger, lower socioeconomic population. Women generally consider their lives unchanged or improved because of these unplanned births. However, unhealthy aspects of some unplanned pregnancies include self-blame and negative feelings toward both the father and baby. Furthermore, a considerable number of young women lack adequate birth control knowledge, and they desire more family planning information from their physicians.