MEDLINE Abstracts: Women, Poverty, and Health

June 18, 2002

MEDLINE Abstracts: Women, Poverty, and Health

This easy-to-navigate collection of recent MEDLINE abstracts compiled by the editors at Medscape Women's Health focuses on the relationship between poverty and the health of women in the United States and Canada.

Elliot NL, Quinless FW, Parietti ES
J Community Health Nurs. 2000;17:211-224

In 1996, the members of the St. Columba Collaboration conducted a grassroots neighborhood assessment of a Hispanic area in Newark, New Jersey. This assessment was undertaken during an era of significant political and policy change in New Jersey. As a community-driven and implemented effort, the processes, methods, and outcomes of this assessment provide lessons on community activism, political awareness, and strategic planning. Quantitative surveys were distributed to local residents as well as users of the various services provided through Collaboration programs. Ten qualitative focus groups were held among various Collaboration groups. A total of 471 surveys were returned from a door-to-door distribution and 295 surveys were returned from users of Collaboration programs. Findings from both the quantitative and qualitative components were surprisingly similar. It was striking to note that youth violence, domestic violence, crime, and lack of job skills surpassed poor housing and chronic health problems, including HIV/AIDS and drug and alcohol addiction, as the most noted neighborhood problems. Overwhelmingly, social, welfare, and environmental issues were identified as priority items in a neighborhood marked by extreme poverty, poor childhood immunization rates, high HIV/AIDS rates, and high incidence of childhood asthma. Focus group findings revealed that stressful daily life events and circumstances far overshadowed health and wellness concerns. Recommendations emanating from the St. Columba Neighborhood needs assessment included: (a) establishment of principled partnerships between the Collaboration and other regional entities to extend capacity to design and implement solutions (e.g., partnerships with other higher education institutions, health care agencies); (b) development of strategic planning processes and procedures within the Collaboration; (c) establishment of collaborative partnerships with other Hispanic community-based organizations for political activism; and (d) reorganization of the Collaboration's internal structure and functions to capitalize on opportunities for change. Significant outcomes from this process, in evidence 4 years after the 1996 neighborhood assessment, include: (a) a successful grant application to study violence against Hispanic women, (b) a research program investigating the nature and extent of clinical depression among Hispanic women, (c) establishment of a teenage pregnancy program, (d) English classes for Hispanic women seeking language skills and eventual employment, and (e) partnership extended to the New Jersey Institute of Technology.

Reutter L, Neufeld A, Harrison MJ
Can J Nurs Res. 2000;32:75-97

Reducing health inequities associated with poverty is an important public health nursing role. This article describes the scope of research on the health of low-income Canadian women. The research included was published in English-language peer-reviewed journals between 1990 and 1997. The 26 articles retrieved are summarized according to the focus of the study and the composition of the sample. Most addressed personal health practices and health status. Only one intervention study was identified. The studies and the findings of this analysis are discussed in relation to three recommendations for research on women's health: an emphasis on social context, including the structural conditions affecting women's health; active participation of women in the research process; and recognition of diversity among low-income women. Suggested priority areas for future research are: intervention studies; studies addressing the structural context of the lives of low-income women; research strategies that enhance the participation of women in the research process; and increased involvement of diverse groups of women such as homeless women and women of varied ethnic backgrounds, including First Nations women.

Ennis NE, Hobfoll SE, Schroder KE
Am J Community Psychol. 2000;28:149-173

We examined the differential impact of chronic versus acute economic stress on depressive mood among a sample of 1241 low-income, single, European and African American women. Based on Hobfoll's (1988, 1989) conservation of resources (COR) theory, we predicted that acute resource loss would be more distressing than chronic economic lack. That is, although chronically impoverished conditions are stressful, the attendant resource losses created will be more distressing. We further predicted that mastery and social support would be more beneficial in offsetting the negative consequences of acute resource loss than the negative consequences of chronic economic lack, because acute loss creates identifiable demands that resources may address. Hence, we hypothesized that mastery and social support would show stress buffering effects only for material loss, not chronic lack. The findings generally supported the hypotheses, but mastery buffered only European American women's resource loss and social support buffered only African American women's resource loss. The findings are discussed in light of implications for prevention within theoretical and cultural contexts.

Rosenberg MW, Wilson K
Soc Sci Med. 2000;51:275-287

It is often said that women live longer than men, but suffer more illnesses throughout their lives. It has also been demonstrated in various studies of women's health that measures of health and health behaviour vary over different geographic scales. Added into this mix is the fact that historically more women than men in relative terms are found on the lower rungs of the socio-economic ladder. What has not been so well-developed is our understanding of the connections among health, gender, poverty and especially location. In 1998, Statistics Canada released the second wave of the National Population Health Survey (NPHS-2). Included with the NPHS-2 public use microdata file are measures of health status, gender, income and location which can be analyzed in the form of logistic regression models. Results are reported which provide a better understanding of the relative roles that gender, poverty and location play in the geography of inequalities.

McLaughlin DK, Jensen L
Gerontologist. 2000;40:469-479

Poverty risks among elders are shaped in critical ways by their work history, demographic characteristics, current marital status, and residential context. Using 25 years of data from the Panel Study of Income Dynamics, we combined past occupation and work history of elders and their spouses with information on current marital status and residence to estimate discrete time event history models of first transitions into poverty after reaching age 55. Education, work history, and preretirement wages contributed to men's and some women's probability of becoming poor. Work history remained an important predictor of transitions into poverty, even after controlling for preretirement wages and human capital. Metropolitan residence was associated with a lower probability of making transitions into poverty. This residential difference was not appreciably attenuated in three of four elderly subgroups after measures of work history, preretirement wages, current life events, and demographic characteristics of the elders were included in the models.

O'Malley AS, Forrest CB, O'Malley PG
J Fam Pract. 2000;49:141-146

Background: Because of their challenging social and economic environments, low income women may find particular features of primary care uniquely important. For this qualitative study we explored which features are priorities to women from low-income settings and whether those priorities fit into an established primary care framework.
Methods: We performed a qualitative analysis of 4 focus groups of women aged 40 to 65 years from 4 community health clinics in Washington, DC. Prompted by semistructured open-ended questions, the focus groups discussed their experiences with ambulatory care and the attributes of primary care that they found important. The focus groups were audiotaped, and the tapes were transcribed verbatim and coded independently by 3 readers.
Results: The comments were independently organized into 5 content areas of primary care service delivery plus the construct of patient-provider relationship in the following order of frequency: accessibility (37.4%), the physician patient relationship (37.4%), comprehensive scope of services (11.5%), coordination between providers (6.8%), continuity with a single clinician (3.7%), and accountability (3.2%). Commonly reported specific priorities included a sense of concern and respect from the clinicians and staff toward the patient, a physician who was willing to talk and spend time with them (attributes of the physician-patient relationship), weekend or evening hours, waiting times (attributes of organizational accessibility), location in the inner city and on public transport routes (an attribute of geographic accessibility), availability of coordinated social and clinical services on-site; and, availability of mental health services on-site (attributes of comprehensiveness and of coordination).
Conclusions: All attributes of care that were priorities for low-income women fit into 1 of 6 content areas. Specific features within the content areas of accessibility, physician patient relationship, and comprehensiveness were particularly important for these women.

Soler H, Quadagno D, Sly DF, Riehman KS, Eberstein IW, Harrison DF
Fam Plann Perspect. 2000;32:82-88,101

Context: Women's protection against HIV and sexually transmitted diseases (STDs) depends upon their ability to negotiate safer sex. It is important to know how cultural norms and gender roles, which vary by ethnicity, may either constrain or encourage negotiation of condom use.
Methods: Questionnaires were completed by 393 low income non-Hispanic black, Hispanic and non-Hispanic white women who were sexually active and attending family planning and STD clinics and other public health and social service centers in Miami in 1994 and 1995. Multivariate logit techniques were used to identify ethnic differences in relationship dynamics and to determine couple- and individual-level factors associated with consistent use, occasional use or nonuse of condoms.
Results: Black and Hispanic women reported higher levels of consistent condom use (15-17%) than did white women (4%). Nearly all black and white women (90-95%) said that they were extremely or somewhat comfortable talking about condoms with their partner, whereas 76% of Hispanic women did so. A larger proportion of Hispanic women (55%) reported joint contraceptive decision-making than did black women (26%) or white women (31%). Among women who reported that their partner made contraceptive decisions, 28% used condoms consistently or occasionally, compared with 24% among women who made the decision themselves. When the couple made the decision jointly, 41% of them were condom users. Hispanic women scored the lowest on a scale of condom-related self-efficacy, yet also reported the highest levels of confidence in their condom negotiating skills. Multivariate analysis indicated that, compared with white women, black and Hispanic women were more likely to be consistent condom users than nonusers (odds ratios, 10.2 and 18.9, respectively). Women who shared financial decision-making with their partner were almost 80% less likely to be a consistent condom user, and women who did not participate in financial decisions were more than 90% less likely to do so, than were women who made monetary decisions independently.
Conclusions: HIV prevention and intervention programs should emphasize birth control discussion between partners and the development of condom-related self-efficacy and negotiation skills, and these programs also should customize prevention messages according to ethnicity and social context.

Ruiz JD, Molitor F, McFarland W, et al.
West J Med. 2000;172:368-373

Objective: To estimate the prevalence of human immunodeficiency virus (HIV) infection, sexually transmitted diseases, and hepatitis and the associated sexual and drug-using behavior among women residing in low-income neighborhoods in 5 northern California counties.
Methods: From April 4, 1996, to January 6, 1998, women aged 18 to 29 years were recruited door-to-door from randomly selected street blocks within 1990 census block groups below the 10th percentile for median household income for each county.
Results: Of 24,223 dwellings enumerated, contact was made with residents from 19,546 (80.7%). Within contacted dwellings, 3,560 eligible women were identified and 2,545 enrolled (71.5%). Weighted estimates for disease prevalence were HIV infection, 0.3% (95% confidence interval, 0.1%-0.4%); syphilis, 0.7% (0.3% 1.1%); gonorrhea, 0.8% (0.3%-1.3%); chlamydia, 3.3% (2.4%-4.8%); herpes simplex virus, type 1, 73.7% (71.6%-76.9%); herpes simplex virus, type 2, 34.4% (29.9%-39.0%); hepatitis A, 33.5% (28.3%-38.7%); chronic hepatitis B, 0.8% (0.3%-1.2%); and hepatitis C, 2.5% (1.4%-3. 6%). Condom use at last sexual intercourse with a new partner was reported by 44.0% (33.9%-54.1%). Injection drug use in the last 6 months was reported by 1.8% (1.0%-2.7%).
Conclusions: The Young Women's Survey provided population-based estimates of the prevalence of 8 infectious diseases and related risk behavior within a population for whom data are often difficult to collect. Population based data are needed for appropriate targeting and planning of primary and secondary disease prevention.

Flaskerud JH, Nyamathi AM
J Health Care Poor Underserved. 2000;11:326-342

Collaborative inquiry is a form of research in which researchers and participants work collaboratively as partners. The purpose of this paper is to demonstrate the process of collaborative inquiry through an example of a longitudinal, community-based study conducted over a six-year period. The research program focused on HIV education, counseling, and antibody testing with low-income Latina women attending a nutrition program for women, infants, and children (WIC) in Los Angeles. Collaborative, community-based inquiry emerges from the community and uses members of the targeted group to design the program, convey the message, act as advocates, evaluate the outcomes of the program, and disseminate research findings. The goal is empowerment and emancipation of both participants and researchers. Five areas in the conduct of community-based collaborative inquiry are demonstrated here: program design, implementation, evaluation, dissemination of the results of the program, and empowerment and emancipation.

Crosby RA, Yarber WL, Meyerson B
Public Health Nurs. 2000;17:53-60

This study sought to determine HIV prevention strategies other than male condom use employed by low-income women who have sex with men (WSM) and to identify variables receiving Women, Infants, and Children (WIC) benefits in 21 Missouri counties was conducted. The response rate was 58%, with 2,256 completed questionnaires returned. Women were asked to indicate one or more of nine methods they had ever used to prevent HIV infection. Women were also asked about their use of male condoms, preference for male condoms versus female condoms, and which partner usually made decisions about STD/HIV prevention. Of the 2,256 questionnaires returned, 1,325 WSM indicated use of at least one HIV prevention strategy other than condom use. Strategies were: being tested for HIV (68.2%), partner being tested for HIV (44.1%), asking partner about his sex history (41.1%), using oral contraceptives (18.8%), asking him if he has HIV (13.7%), douching (11.8%), withdrawal (9.4%), and having anal or oral sex (6.6%). Common predictors of these strategies were race, education, history of STD, condom use, and marital status. Basic misunderstandings about HIV prevention are common in specified subpopulations of low-income women. HIV prevention programs for low-income WSM should capitalize on women's efforts to prevent HIV by designing programs to help women replace ineffective prevention strategies with effective prevention strategies.

Jackson R, Bimla Schwarz E, Freedman L, Darney P
Contraception. 2000;61:351-357

We performed a multivariate analysis to determine factors associated with knowledge and willingness to use emergency contraception in a consecutive sample of 371 post partum women from an inner-city public hospital. Women were queried about previous contraceptive use, pregnancy history including abortions and unplanned pregnancies, and demographic characteristics. Outcomes included knowledge of emergency contraception and willingness to use it. Questionnaires were conducted in person, in English or Spanish. Of 371 women, 3% had used emergency contraception, 36% had heard of it, and 7% knew the correct timing for use. Two-thirds of the population indicated a willingness to use emergency contraception in the future. Factors positively associated with knowledge included being a teenager or more than 30 years old, prior use of condoms, and history of an elective abortion. Being multiparous, monolingual Spanish-speaking, or Asian were negatively associated with knowledge. Willingness to use emergency contraception was positively associated with being multiparous and negatively associated with a higher income, moral or religious objections to the use of emergency contraception, a belief that it is unsafe or a perception that it is an abortificient. Knowledge about emergency contraception, especially correct timing, remains low. Multiparous women should receive increased education given their lack of knowledge but willingness to use emergency contraception. In order to increase the acceptability of emergency contraception, educational efforts must include accurate information about its mechanism of use and safety.

Lauby JL, Smith PJ, Stark M, Person B, Adams J
Am J Public Health. 2000;90:216-222

Objectives: This study examined the effects of a multisite community-level HIV prevention intervention on women's condom-use behaviors.
Methods: The theory based behavioral intervention was implemented with low-income, primarily African American women in 4 urban communities. It was evaluated with data from pre- and postintervention cross-sectional surveys in matched intervention and comparison communities.
Results: At baseline, 68% of the women had no intention of using condoms with their main partners and 70% were not using condoms consistently with other partners. After 2 years of intervention activities, increases in rates of talking with main partners about condoms were significantly larger in intervention communities than in comparison communities (P = .03). Intervention communities also had significant increases in the proportion of women who had tried to get their main partners to use condoms (P = .01). The trends for condom use with other partners were similar but nonsignificant.
Conclusions: Many women at risk for HIV infection are still not using condoms. Community-level interventions may be an effective way to reach large numbers of women and change their condom-use behaviors, particularly their behaviors with regard to communication with main sex partners.

Sikkema KJ, Kelly JA, Winett RA, et al.
Am J Public Health. 2000;90:57-63

Objectives: Women in impoverished inner-city neighborhoods are at high risk for contracting HIV. A randomized, multisite community-level HIV prevention trial was undertaken with women living in 18 low-income housing developments in 5 US cities.
Methods: Baseline and 12-month follow-up population risk characteristics were assessed by surveying 690 women at both time points. In the 9 intervention condition housing developments, a community-level intervention was undertaken that included HIV risk reduction workshops and community HIV prevention events implemented by women who were popular opinion leaders among their peers.
Results: The proportion of women in the intervention developments who had any unprotected intercourse in the past 2 months declined from 50% to 37.6%, and the percentage of women's acts of intercourse protected by condoms increased from 30.2% to 47.2%. Among women exposed to intervention activities, the mean frequency of unprotected acts of intercourse in the past 2 months tended to be lower at follow-up (mean = 4.0) than at baseline (mean = 6.0). These changes were corroborated by changes in other risk indicators.
Conclusions: Community-level interventions that involve and engage women in neighborhood-based HIV prevention activities can bring about reductions in high-risk sexual behaviors.

Napravnik S, Royce R, Walter E, Lim W
AIDS Patient Care STDS. 2000;14:411-420

In an effort to understand issues affecting prenatal care access and utilization from the perspectives of human immunodeficiency virus (HIV)-infected women who receive inadequate prenatal care, we conducted three in-depth qualitative and quantitative interviews. From a thematic analysis of the narrative interviews, four broad areas emerged as pertinent to these women's prenatal care experiences. These were issues related to pregnancy, HIV, psychosocial conditions, and the health care system. For these women, the barriers to prenatal care utilization included the unexpected and unplanned nature of the pregnancy and mental health issues related to HIV infection. Poverty, periodic homelessness, addiction to illicit substances, and lack of social support were also important barriers. Furthermore, perceptions of the health care system as threatening, including fears related to consequences of disclosing illicit activities, discrimination, and breach of confidentiality emerged as salient barriers. Facilitating factors included the pregnancy being experienced as a life-transforming event, concern for their children, especially preventing HIV-1 vertical transmission, availability of treatment, and support from health care professionals. Prominent throughout the interviews were the women's mental health concerns and need for professional support.

Ettlinger T
Public Health Nurs. 2000;17:207-210

The following article describes the efforts of a group of rural Vermont maternal child health (MCH) nurses who addressed alcohol risk for the pregnant mothers they served through the Women, Infants, and Children (WIC) Supplemental Nutrition program. As front-line providers, MCH nurses are in a position to both improve the detection of problem drinking during pregnancy and to strengthen maternal alcohol prevention and intervention initiatives. Results showed that a more refined screening for alcohol provided an opportunity to promote harm reduction.

Guttman N, Zimmerman DR
Soc Sci Med. 2000;50:1457-1473

Nourishing infants presents women today with choices, desires, obligations and constraints. Despite mounting evidence about the health, psychosocial and societal benefits of breastfeeding both for women and infants, current breastfeeding rates worldwide are far from optimal, particularly among low-income women. Many mothers choose to use infant formula. Drawing from structured interviews with 154 mothers from an urban low-income multiethnic population in the United States, a typology of mothers' feelings about their infant feeding method is developed. Findings indicate that regardless of their feeding method, mothers tended to attribute higher health benefits to breastfeeding and perceived community norms as probreastfeeding. They differed in their rating and perceptions of logistics and the extent to which benefits mattered in their infant-feeding decision. Contradictions associated with the practice of breastfeeding even among mothers who breastfed, were reflected in their perceptions of social disapproval of breastfeeding in public, reports of ridicule by friends, lack of support from some health providers, and difficulties associated with working. A typology of mothers' emotional states resulting from such contradictions summarizes the findings and underscores how some mothers who did not, but would have liked to breastfeed, may be subjected to feelings of guilt and deprivation. Implications for educational interventions are to amplify prenatal infant feeding consultations and address ways to overcome logistical and apprehension barriers.

Milligan RA, Pugh LC, Bronner YL, Spatz DL, Brown LP
J Midwifery Womens Health. 2000;45:246-252

Breastfeeding has been identified as a possible deterrent to the development of osteoporosis and breast cancer in women. In addition, infants who are breastfed exclusively for at least 4 months reportedly have fewer incidence of SIDS, ear infection, diarrhea, and allergies. Further, low income women who breastfeed may be empowered by the experience. Increasing the frequency and duration of breastfeeding is recognized as a national priority, particularly for low income, minority women. Yet, recent national data indicate that in 1997, only 16.5% of low income mothers breastfed for at least 6 months. Short breastfeeding duration in low income women may be due to problems unique to them; thus, consistent and comprehensive breastfeeding support should be provided by midwives, nurses, lactation consultants, and peer counselors who are skilled in culturally sensitive management of lactation within the context of limited financial and social resources. This article focuses on the benefits of breastfeeding, and factors that may influence its duration. It also explores culturally relevant strategies as well as suggested interventions to increase breastfeeding duration among low-income women.

Mahoney MC, James DM
J Fam Pract. 2000;49:529-533

Background: Although the proportion of women who breastfeed is known to vary by demographic group, breastfeeding practices have not been sufficiently studied among urban, lower income African American populations seen in family medicine centers.
Methods: A cross-sectional design was used to examine demographic, clinical, and attitudinal factors that affect anticipated infant feeding practices reported by postpartum women from a low-income, urban family practice setting. Data was analyzed using chi-square, odds ratios (OR), and multiple logistic regression techniques.
Results: Among 66 respondents, only 3 subjects (4.5%) indicated that they planned to breastfeed exclusively, while an additional 11 subjects (16.7%) reported plans to use a combination of bottle-feeding and breastfeeding. Based on univariate analyses, women with less than 12 years of education were less likely to report anticipated breastfeeding. Otherwise, breastfeeding plans were not associated with subject demographic features or with reproductive characteristics. Respondents planning to bottle-feed noted that breastfeeding was too complicated. Logistic regression demonstrated an inverse relationship between level of maternal education and anticipated breastfeeding (OR=0.13, 95% confidence interval [CI], 0.05-0.35), and a direct association for encouragement from the baby's father or the woman's mother to breastfeed and anticipated breastfeeding (OR=12.4; 95% CI, 4.92-31.4).
Conclusions: This study reports unique data regarding anticipated infant feeding practices among patients from an urban, low-income community served by a family medicine center. Findings from this study will be used to develop a family-centered educational intervention involving the mothers, grandmothers, and partners of pregnant patients to promote the benefits of breastfeeding in this community.

Ahluwalia IB, Tessaro I, Grummer-Strawn LM, MacGowan C, Benton-Davis S
Pediatrics. 2000;105:E85

Objective: Beginning in 1990, Georgia's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) initiated 5 new strategies to promote breastfeeding among its pregnant and postpartum clients. These strategies were implemented in 1991, each to be provided as an addition to its standard program of counseling on breastfeeding and distributing appropriate literature: 1) enhanced breastfeeding education, 2) breast pump loans, 3) hospital-based programs, 4) peer counseling, and 5) community coalitions. The enhanced breastfeeding education strategy provides access to a hotline as well as periodic training of staff, and the breast pump loan provides free breast pumps to mothers who want to use them. The hospital-based strategy provides bedside support and counseling to women who have just given birth and includes staff training, as well as a hotline number for women to call after they leave the hospital. The peer-counseling strategy focuses on identifying former WIC participants who have successfully breastfed their infants; these women are recruited to provide support and encouragement to current WIC participants. Finally, the community coalitions approach is designed to identify existing community attitudes about breastfeeding, establish plans to address gaps in breastfeeding services, to develop resource guides on breastfeeding for the community, and to advocate at the community level to support breastfeeding women. The objective of our research was to evaluate the impact of breastfeeding promotion strategies on breastfeeding initiation among WIC participants in Georgia.
Methods: Using data from the Pregnancy Nutrition Surveillance System (PNSS) for 1992-1996, we examined breastfeeding initiation rate during this period and compared rates among 6 different intervention strategies. Also, we used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) to assess breastfeeding initiation and duration among WIC enrollees. We conducted 13 focus groups to understand the experiences of program participants. Ten focus groups were conducted with women who were breastfeeding their infants, 3 each with women from the community coalitions, hospital-based programs, and standard education programs, and 1 with women from the breast pump loan program. Three focus groups were conducted with women who were feeding their infants formula.
Results: PNSS data show that breastfeeding initiation increased in the Georgia WIC program from 31.6% in 1992 to 39.5% in 1996. PRAMS data confirmed the increase in breastfeeding initiation from 33.6% (standard error [SE]: 2.2) in 1993 to 42.1% (SE: 2.4) in 1996 among WIC participants. Both datasets (PRAMS and PNSS) showed breastfeeding initiation to be well below the year 2000 goal of 75%. Overall, PRAMS data show a high breastfeeding initiation among non-WIC participants (range: 64.7% [SE: 2.2]) for 1994 to 70.1% (SE: 2.2) in 1996. The percent change between 1993 and 1996 was 8% for non-WIC participants, and it was 25% for the WIC participants among those responding to the PRAMS questionnaire. Data from PRAMS indicated no statistical change in the percentage of WIC enrollees who breastfed their infants for 8 weeks or more; this estimate was 18.3% (95% confidence interval (CI): 14.9-21.8) in 1993 and 19.4% (95% CI: 15.7-23.2) in 1996, well below the Healthy People 2000 objective of 50% at 6 months. According to PNSS data, the largest increases in breastfeeding initiation for 1992 to 1996 were among younger women (≤19 and 20-24 years old), those with no college (less than high school and high school only), unmarried, and black women. The smallest increases during this period were among older women (30+), those with more than a high school education, and women who were white, Hispanic, or from other ethnic or racial groups. The PRAMS data (1993-1996) generally display similar results, but the pattern by marital status demonstrated larger increases for married women than for unmarried women.

Robbins JM, Vaccarino V, Zhang H, Kasl SV
Am J Public Health. 2001;91:76-83

Objectives: This study examined the associations of poverty income ratio (PIR), education, and occupational status with type 2 diabetes prevalence among African American and non-Hispanic White (White) women and men aged 40 to 74 years.
Methods: We analyzed cross-sectional data from the Third National Health and Nutrition Examination Survey, controlling for age and examination-related variables.
Results: Among African American women, there was a strong, graded association between PIR and diabetes, which remained significant after other risk factors were adjusted for. All 3 variables were significantly associated with diabetes among White women. Among White men, only PIR was significantly associated with diabetes. Controlling for risk factors substantially attenuated these associations among White women. There were no significant associations for African American men.
Conclusions: Socioeconomic status is associated with type 2 diabetes prevalence among women, but not consistently among men. Diabetes prevalence is more strongly associated with PIR than with education or occupational status. These associations are largely independent of other risk factors, especially among African American women. Economic resources should be addressed in efforts to explain and reverse the increasing prevalence of diabetes in the United States.

Behera SK, Winkleby MA, Collins R
Am J Health Promot. 2000;14:301-305

Focus groups were conducted with low-income African-American women in six different community settings in Northern California to assess their awareness of and concern for cardiovascular disease (CVD). These women had low awareness of the prevalence of CVD, attributed CVD to stress and low socioeconomic status, saw the media as an important source of health-related knowledge, and saw a need for more community awareness on CVD among African-American people.

Solomon LJ, Scharoun GM, Flynn BS, Secker-Walker RH, Sepinwall D
Prev Med. 2000;31:68-74

Background: This study tested the impact of free nicotine patches plus proactive telephone peer support to help low-income women stop smoking.
Methods: A total of 214 Medicaid-eligible women smokers of childbearing age were randomized to receive free nicotine patches through the mail or free nicotine patches through the mail plus the provision of proactive support by telephone from a woman ex-smoker for up to 3 months. Assessments were conducted by telephone at baseline, 10 days, and 3 and 6 months after enrollment.
Results: At the 3-month follow-up, significantly more women in the patch plus proactive telephone support condition were abstinent (42%) compared to the patch only condition (28%) (P = 0.03). Similarly, more women in the experimental condition were abstinent at both the 10-day and 3-month assessments (32 v 19%, P = 0.02). However, differences were not found at the 6-month follow-up, suggesting that the addition of proactive telephone peer support enhanced short-term, but not long-term cessation. Conclusions: This is the first study to demonstrate a beneficial effect for the addition of proactive telephone support as an adjunct to free nicotine replacement in a low-income population.

Zapka JG, Pbert L, Stoddard AM, Ockene JK, Goins KV, Bonollo D
Am J Public Health. 2000;90:78-84

Objectives: This study assessed providers' performance of smoking cessation counseling steps with low-income pregnant and postpartum women receiving care at community health centers.
Methods: WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) program staff, obstetric clinicians, and pediatric clinicians at 6 community health centers were asked to complete surveys. Smoking intervention practices (performance), knowledge and attitudes, and organizational facilitators were measured. Factors associated with performance were explored with analysis of variance and regression analysis.
Results: Performance scores differed significantly by clinic and provider type. Providers in obstetric clinics had the highest scores and those in pediatric clinics had the lowest scores. Nurse practitioners and nutritionists had higher scores than other providers. Clinic type, greater smoking-related knowledge, older age, and perception of smoking cessation as a priority were independently related to better counseling performance.
Conclusions: Mean performance scores demonstrated room for improvement in all groups. Low scores for performance of steps beyond assessment and advice indicate a need for emphasis on the assistance and follow-up steps of national guidelines. Providers' own commitment to helping mothers stop smoking was important.

Macleod U, Ross S, Gillis C, McConnachie A, Twelves C, Watt GC
Ann Oncol. 2000;11:105-107

Background: This study describes and compares the pathological prognostic factors and surgeon assessment of stage of breast cancer of women living in affluent and deprived areas to assess whether clinical stage at presentation may explain the known poorer survival outcomes for deprived women.
Patients and Methods: A population-based review of the case records of 417 women with breast cancer was carried out.
Results: No difference in pathological criteria was found between the 88% of women living in affluent and deprived areas for whom such data were available. Clinical assessment of the remaining 50 cases showed that women living in deprived areas were more likely to present with locally advanced or metastatic disease.
Conclusion: The poorer survival of women from deprived areas with breast cancer may be explained by more deprived women presenting with advanced cancers.

Hardy RE, Ahmed NU, Hargreaves MK, et al.
J Health Care Poor Underserved. 2000;11:45-57

Low-income women have a high mortality from breast cancer. Yet, they participate in breast cancer early detection screening programs less than women in the general population. An intervention study to improve screening mammography rates of low-income women participating in Tennessee's TennCare program (state Medicaid and Medicare program) revealed significant barriers to reaching these women. Intervention methods included mail, telephone calls, and home visits. Results indicate that only 38 percent of the women could be contacted for a baseline survey. Reasons for noncontact included absence from home (39 percent), having moved (22 percent), refusal to participate (17 percent), having no physical domicile (15 percent), language barriers (4 percent), and miscellaneous other factors (4 percent). Women with telephones tended to have a relatively higher economic status and were more successfully reached than women without telephones. These findings provide useful insights for future program planning and research design.

Fowler BA
J Womens Health Gend Based Med. 2000;9:175-184

Before passage of the Federal legislation, National Breast and Cervical Cancer Screening Act (NBCCSA) in 1991, over half the states (65%) had preexisting laws requiring health insurers, for example, Blue Cross/Blue Shield and HMOs, to provide services beyond the federal coverage for mammography screening and care following breast cancer. This study examined mammography screening legislation across the states. Data were derived from telephone interviews with six NBCCSA program directors or coordinators from July 1999 to October 1999. A review of existing documents from the Institute for Women's Policy Research, online data from the Centers for Disease Control and Prevention, and state laws provided by the Governmental Affairs Division of the American Cancer Society was undertaken. There was considerable variability in relation to factors potentially related to the extent of state laws. The states with the lowest age-adjusted breast cancer mortality rates among black women had the least comprehensive state legislation. Several states with the least percent of women above the federal poverty threshold also had the least comprehensive legislation. Some states had a wide gap between the provision of health insurance coverage and scope of legislation to ensure care following breast cancer. Some states were more aggressive in their efforts to ensure care following breast malignancy at diagnosis. Lessons could be learned by states that enacted the least comprehensive legislation. With the passage of the federal legislation nearly a decade ago, more women are receiving timely and available mammography screening, resulting in earlier diagnosis of breast cancer. Greater efforts must be undertaken by all states to provide the full array of breast cancer treatment for women in the millennium.

Ekeh AP, Alleyne RS, Duncan AO
J Natl Med Assoc. 2000;92:372-374

Mammography continues to play a strategic role in breast cancer diagnosis. Its place in the urban inner-city population among individuals in lower socioeconomic groups has been shown to differ from contemporary trends. A retrospective review of all women diagnosed with breast cancer over a 5-year period (1993 to 1997) in an inner-city hospital was undertaken. Primary cancers (128) were diagnosed in 123 patients during this period. Only 17 patients (12%) had their disease diagnosed with the help of mammography. All other 111 patients were diagnosed clinically. All 17 patients diagnosed by mammogram evaluation had Stage II carcinoma or earlier in contrast with three-fourths of the clinically detected group of patients. Twelve percent of the black women were diagnosed by mammography, whereas 21% of white patients were diagnosed by the same modality. All these proportions are lower than those cited in the regular literature. Better utilization of mammography needs to be applied in inner-city populations to improve early detection of breast cancer.

Regan J, Lefkowitz B, Gaston MH
J Ambulatory Care Manage. 1999;22:45-52

Objective: The elimination of health status gaps among minority and low income populations is part of the mission of community health centers (CHCs). Cervical and breast cancer incidence and mortality are related to both minority and socioeconomic status, and CHCs are in a unique position, by virtue of their target population, to effect positive outcomes through screening and early detection.
Methods: Completed in 1995, the survey described in this article included questions from the 1992 NHIS Cancer Supplement, which collected information on the utilization of cancer-screening services, including Pap smear testing, mammography, and clinical breast examination.
Results: CHCs are providing access to Pap smear testing, mammography, and clinical breast examination for women who are at an increased risk for morbidity and mortality associated with cancers of the cervix and breast. A higher proportion of CHC women of most racial and ethnic groups and women below poverty level are up to date on cancer screening than comparison groups. In most cases, CHC women meet or exceed the Healthy People 2000 objectives for the nation.

Kalichman SC, Williams E, Nachimson D
J Am Med Womens Assoc. 2000;55:47-50

Objective: Breast cancer is the most common cancer in women, and African-American women are less likely to detect breast cancer at its early stages. Few controlled trials of interventions to increase breast self-examination (BSE) among low-income minority women have been conducted. Our objective was to test a small-group workshop intended to build BSE skills and promote BSE among low-income African-American women.
Methods: A randomized community field trial tested a BSE skills-building workshop based on social cognitive theory of behavior change compared to a matched sexually transmitted diseases prevention workshop, with one- and three-month follow-ups for assessing increased practice of BSE.
Results: Women who did not regularly practice BSE and participated in a BSE skills-building workshop were more likely to practice BSE than women in the comparison intervention at the one- (OR = 3.5, p = 0.04) and three-month follow-ups (OR = 4.9, p = 0.01). These results were not related to risk perceptions heightened by the intervention. Across conditions and controlling for covariates in a multivariate model, performing regular BSE was most closely associated with having received any formal BSE instruction.
Conclusion: BSE skills building can effectively increase use of BSE among low-income African-American women who face multiple and competing health risks. The small-group experience is an important element in fostering norms for practicing BSE and enhancing BSE practices.

Blustein J
Womens Health Issues. 2000;10:47-53

The lack of prescription drug coverage under the Medicare program translates into high out-of-pocket drug costs for seniors. This nationwide study of older Americans with hypertension ("high blood pressure") demonstrates that women bear the disproportionate burden of this gap in Medicare coverage. Women form the majority of older people with hypertension, and are less likely to have supplemental policies to cover the cost of the prescription drugs that are needed to treat the disease. Moreover, women have substantially lower incomes. Despite their economic vulnerability, older women with hypertension spend substantially more on prescription drugs than men.

Bierman AS, Clancy CM
Womens Health Issues. 2000;10:59-69

Growth in capitated Medicare has special ramifications for older women who comprise the majority of Medicare beneficiaries. Older women are more likely than men to have chronic conditions that lead to illness and disability, and they often have fewer financial and social resources to cope with these problems. Gender differences in health status have a number of important implications for the financing and delivery of care for older women under both traditional fee-for-service Medicare and capitation. The utilization of effective preventive interventions, new therapeutic interventions for the management of common chronic disorders, and more cost-effective models of chronic disease management could potentially extend the active life expectancy of older women. However, there are financial and delivery system barriers to achieving these objectives. Traditional FFS Medicare has gaps in coverage of care for chronic illness and disability that disproportionately impact women. Managed care potentially offers flexibility to allocate resources creatively, to develop new models of care, and offer enhanced benefits with lower out-of-pocket costs. However, challenges to realizing this potential under Medicare managed care with unique implications for older women include: possible gender bias in capitation payments, risk selection, inadequacy of risk adjustment models, benefit and market instability, and disenrollment patterns.

Garrett B, Holahan J
Health Aff (Millwood). 2000;19:175-184

This DataWatch examines the health insurance coverage of former welfare recipients who left welfare between January 1995 and mid-1997, using data from the 1997 National Survey of America's Families. Although the majority of women who left welfare were working, only 33 percent of these women obtained health coverage through their jobs. Rates of uninsurance increase with the number of months since leaving welfare and with declines in Medicaid coverage. A year or more after leaving welfare, 49 percent of women and 30 percent of children were uninsured.

Wright PJ, Fortinsky RH, Covinsky KE, Anderson PA, Landefeld CS
J Am Geriatr Soc. 2000;48:124-130

Objectives: Older black patients are at risk for underutilization of preventive services. Our objectives were to assess the delivery of five preventive services in Title 330-funded health centers in low income neighborhoods in Cleveland, Ohio, and to determine the association of health system factors and health status with the delivery of these services.
Design: A cross-sectional study. SETTING: Four neighborhood health centers in low income neighborhoods of Cleveland, Ohio.
Participants: A total of 683 black men and women, aged 70 and older, who regarded the health center as their primary source of outpatient care. MEASUREMENTS: Demographic characteristics, independence in basic and instrumental activities of daily living, comorbidity scores, and perceived access were determined by telephone interview. We reviewed charts to determine whether each of five preventive service goals were obtained: influenza vaccination within 1 year; pneumococcal vaccination at any time; mammography within 2 years; Papanicolau screening within 1 year or twice at any time in the past with documentation of normal results; and fecal occult blood testing within 2 years.
Results: The defined goals for influenza vaccination, pneumococcal vaccination, mammography, Papanicolau screening, and fecal occult blood testing were achieved for 59%, 64%, 59%, 51%, and 17% of patients, respectively. Influenza and pneumococcal vaccines were obtained more often in persons with greater comorbidity. Mammography and Papanicolau smear were obtained more often in patients without of ADL or IADL impairments. The four clinical sites varied substantially in the delivery of each preventive service. More frequent office visits were associated with greater delivery of all five preventive services. This relationship persisted in multivariable analyses controlling for health status and clinical site.
Conclusions: This study shows that Title 330 federally supported neighborhood health center sites providing primary care to older blacks in Cleveland achieved high rates of performance in four of the five recommended preventive services. In addition, preventive services practices were associated with prognostically relevant health status information. The frequency of office visits was related strongly and consistently to the performance of the various preventive services, indicating that more, not fewer, office visits may be necessary to achieve Healthy People 2000 targets.

Morris HM, Kerr JC, Wood MJ, Haughey M
J Community Health Nurs. 2000;17:115-126

Health promotion is increasingly being recognized as making an important contribution to the well-being of Canada's seniors. Most research relating to this topic, however, has focused on middle-income senior men and women. An exploratory study using ethnographic methods was conducted to explore and describe the health promotion experience of senior women living on limited incomes. Interviews with a total of 11 urban senior women living on limited incomes were analyzed. A major finding of this study was that the women utilized a wide variety of "ways of living" that are presented in the model, Health Promotion as Self Nurturance. Health promotion was perceived to be influenced by living on a limited income by most participants; however, 3 of the participants believed that their health status and income level were unrelated. Findings are discussed and implications for community health nurses are offered.

Ganesan K, Teklehaimanot S, Swartz JB, Reuben DB
J Am Geriatr Soc. 2000;48:669-672

Objective: To examine sociodemographic, health and preventive health practices associated with hormone replacement therapy (HRT) use in urban community-dwelling older women.
Design: Survey. SETTING: Community-based meal sites throughout the city of Los Angeles.
Participants: A convenience sample of 705 community-dwelling women older than age 60 who completed questionnaires for the Prevention for Elderly Persons Program.
Measurements: Demographic and life style characteristics, functional status, preventive practices, and current and past use of HRT.
Results: Among the 705 women surveyed, 13% reported current use and 17% reported past use of HRT. Current users were more likely to be younger and more likely to report a history of osteoporosis, hysterectomy, and calcium use than never users. White women were more likely to be current users than black women.
Conclusions: Only a small proportion of the older urban women studied are currently using HRT. In particular, efforts to increase the use of these preventive services need to focus on black women and women who do not have a prior history of osteoporosis.

Appling SE, Allen JK, Van Zandt S, Olsen S, Brager R, Hallerdin J
J Womens Health Gend Based Med. 2000;9:57-64

Hormone replacement therapy (HRT) can have significant long-term health benefits in postmenopausal women, yet rates of HRT use are low, especially in low-income urban women. Previous research has revealed that knowledge of menopause is a key predictor of HRT use in this population. A descriptive cross-sectional survey of 215 perimenopausal and postmenopausal low-income urban women was carried out to characterize knowledge of menopause and HRT and factors associated with knowledge level. Sociodemographic characteristics, patterns of HRT use, and knowledge about menopause and HRT were collected through a structured interview. Results revealed a general lack of knowledge about menopause and HRT, particularly relative to heart disease and the role of HRT in prevention. Major independent predictors of increased knowledge (R2 = 0.31) were having talked with a healthcare provider about HRT, having at least a high school education, and being less than 60 years of age. These findings emphasize the key role of providers in educating this vulnerable population about menopause and HRT and the potential subsequent impact on HRT use.

Gold EB, Sternfeld B, Kelsey JL, et al.
Am J Epidemiol. 2000;152:463-473

A community-based survey was conducted during 1995-1997 of factors related to menopausal and other symptoms in a multi-racial/ethnic sample of 16,065 women aged 40-55 years. Each of seven sites comprising the Study of Women's Health across the Nation (SWAN) surveyed one of four minority populations and a Caucasian population. The largest adjusted prevalence odds ratios for all symptoms, particularly hot flashes or night sweats (odds ratios = 2.06-4.32), were for women who were peri- or postmenopausal. Most symptoms were reported least frequently by Japanese and Chinese (odds ratios = 0.47-0.67 compared with Caucasian) women. African-American women reported vasomotor symptoms and vaginal dryness more (odds ratios = 1.17-1.63) but urine leakage and difficulty sleeping less (odds ratios = 0.64-0.72) than Caucasians. Hispanic women reported urine leakage, vaginal dryness, heart pounding, and forgetfulness more (odds ratios = 1.22-1.85). Hot flashes or night sweats, urine leakage, and stiffness or soreness were associated with a high body mass index (odds ratios = 1.15-2.18 for women with a body mass index > or =27 vs. 19-26.9 kg/m2). Most symptoms were reported most frequently among women who had difficulty paying for basics (odds ratios = 1.15-2.05), who smoked (odds ratios = 1.21-1.78), and who rated themselves less physically active than other women their age (odds ratios = 1.24-2.33). These results suggest that lifestyle, menstrual status, race/ethnicity, and socioeconomic status affect symptoms in this age group.