Hysterectomy: beliefs and attitudes expressed by African-American women

OBJECTIVE

Racial/ethnic differences in the rates of hysterectomy have been noted historically. The aim of this study was to explore the beliefs and attitudes of African-American women regarding hysterectomy recommended for non-life threatening conditions.

METHODS

Women, aged 30-65 years, were recruited from public health clinics and community agencies for participation in focus groups guided by a semi-structured questionnaire. Transcripts were analyzed both manually and using NUD*IST software.

RESULTS

Thirty-eight women participated in six focus groups. Hysterectomy had been recommended for 15% of the women. Four categories and 11 themes emerged from the sessions. Categories included: definitions of hysterectomy and medical indications; resources consulted in the decision-making process; outcomes of hysterectomy; and interactions with the health care community.

CONCLUSION

It is important to assess a patient's perceptions and preferences regarding treatment options. The women in this study advocated the delay or avoidance of surgery, or the use of alternative methods of treatment in lieu of hysterectomy for non-cancerous conditions. Physicians who recommend hysterectomy should consider the attitudes, beliefs, and knowledge of patients.

Developing a video intervention to model effective patient-physician communication and health-related decision-making skills for a multiethnic audience

The ENDOW study is a multisite, community-based project designed to improve decision-making and patient-physician communication skills for midlife African-American, white, and Hispanic women facing decisions about hysterectomy. Based on results of initial focus groups, a patient education video was developed in English and Spanish to serve as the centerpiece of various interventions. The video uses community women to model appropriate decision-making and patient-physician communication skills. Women in the target populations rated the video as useful to very useful and would recommend it to others. The use of theory-driven approaches and pilot testing of draft products resulted in the production of a well-accepted, useful video suitable for diverse populations in intervention sites in several states.

Abuse assessment screen-disability (AAS-D): measuring frequency, type, and perpetrator of abuse toward women with physical disabilities

An interview questionnaire was presented to a multiethnic sample of 511 women, age 18-64 years, at public and private specialty clinics to determine the frequency, type, and perpetrator of abuse toward women with physical disabilities. The four-question Abuse Assessment Screen-Disability (AAS-D) instrument detected a 9.8% prevalence (50 of 511) of abuse during the previous 12 months. Using two standard physical and sexual assault questions, 7.8% of the women (40 of 511) reported abuse. The two disability-related questions detected an additional 2.0% of the women (10 of 511) as abused. Women defining themselves as other than black, white, or Hispanic (i.e., Asian, mixed ethnic background) were more likely to report physical or sexual abuse or both, whereas disability-related abuse was reported almost exclusively by white women. The perpetrator of physical or sexual abuse was most likely to be an intimate partner. Disability-related abuse was attributed equally to an intimate partner, a care provider, or a health professional. This study concludes that both traditional abuse-focused questions and disability-specific questions are required to detect abuse toward women with physical disabilities.

Exploring barriers to utilization of poison centers: a qualitative study of mothers attending an urban Women, Infants, and Children (WIC) Clinic

OBJECTIVE

Prior research regarding poison center utilization identified risk factors for underutilization including race/ethnicity and acculturation. The purpose of this study was to understand factors contributing to underutilization of poison centers by low-income and minority mothers.

METHODS

Focus groups were conducted with women attending an urban Women, Infants and Children clinic. Transcripts were analyzed for themes and key points.

RESULTS

Twenty-two English-speaking mothers and 21 Spanish-speaking mothers participated in 7 groups. Participants viewed poisoning as a serious problem to which all children are susceptible. English-speaking mothers had heard of the poison center but were unaware of services provided. They preferred to use the 911 system, which was viewed as immediate medical assistance and was an easy number to remember. Women questioned the credentials of the poison center staff. Spanish-speaking mothers had limited knowledge of poison centers and were concerned about language barriers.

CONCLUSIONS

To increase utilization of poison centers, educational interventions must address these specific needs and misconceptions and should be produced in Spanish and English versions.

Overview of women's decision making regarding elective hysterectomy, oophorectomy, and hormone replacement therapy

Over 600,000 hysterectomies are performed each year in the United States, the majority of which are to improve quality of life for perimenopausal women. Hysterectomy rates for common conditions differ between African American and white women, and African American women undergo surgery at a younger age for most diagnoses. Many hysterectomies are accompanied by elective oophorectomy, and hormone replacement therapy (HRT) is commonly used, especially among women experiencing surgical menopause, despite questions about its long-term benefits and risks. Despite the high rates of hysterectomy in the United States, little is known about how women make decisions regarding this surgery and, in particular, how ethnic and cultural factors may influence these decisions. This article provides a review of what is currently known about the epidemiology of hysterectomy, oophorectomy, and HRT use and identifies gaps in knowledge about women's decision making, with a special focus on ethnic variations and cultural influences, issues addressed by the Ethnicity, Needs, and Decisions of Women (ENDOW) project.

Decision making, beliefs, and attitudes toward hysterectomy: a focus group study with medically underserved women in Texas

Variations in hysterectomy rates have been associated with assorted physician and patient characteristics, and the disproportionate rate of hysterectomies in African American women has been attributed to a higher prevalence of leiomyomas. The role of women's beliefs and attitudes toward hysterectomy and participation in decision making for medical treatment has not been explored as a source of variance. The purposes of this qualitative study were to explore these constructs in a triethnic sample of women to understand beliefs, attitudes, and decision-making preferences among underserved women; to facilitate development of a quantitative survey; and to inform development of interventions to assist women with such medical decisions. Twenty-three focus groups were conducted with 148 women from community sites and public health clinics. Thirteen self-identified lesbians participated in three groups. Analysis of audiotaped transcripts yielded four main themes: perceived outcomes of hysterectomy, perceived views of men/partners, opinions about healthcare providers, decision-making process. Across groups, the women expressed similar expectations from hysterectomy, differing only in the degree to which dimensions were emphasized. The women thought men perceived women with hysterectomy as less desirable for reasons unrelated to childbearing. Attitudes toward physicians were negative except among Hispanic women. All women expressed a strong desire to be involved in elective treatment decisions and would discuss their choice with important others. Implications for intervention development include enhancing women's skills and confidence to evaluate treatment options and to interact with physicians around treatment choices and creation of portable educational components for important others.

Factors associated with residents' attitudes toward dying patients

BACKGROUND AND OBJECTIVES

Management of the dying patient often elicits anxiety in physicians. This study identified the association of physicians' personal fear of death, tolerance of uncertainty, and attachment style with physician attitudes toward dying patients.

METHODS

Four psychological scales were distributed to family practice residents located in Texas, Missouri, and Maine. The scales were "Death Anxiety," "Death Attitudes," "Physicians' Reactions to Uncertainty," and "Experiences in Close Relationships." The scores from the measures and demographic data were used to determine which factors were associated with physician attitudes toward caring for terminally ill patients.

RESULTS

Completed surveys were received from 157 residents. Younger residents (< 30 years) reported more stress from uncertainty and were more uncomfortable with the care of dying patients. Residents who reported higher death anxiety were also more uncomfortable with caring for dying patients. In a multivariate analysis, uncertainty, death anxiety, and age predicted 26% of the total outcome variance of the death attitudes score.

CONCLUSIONS

Physician tolerance of uncertainty plays a significant role in physician attitudes toward the dying patient. Our findings suggest that decreasing physicians' stress from uncertainty by educating them in the management of the dying patient may improve their attitude toward death and may better prepare them to provide end-of-life care.

Prenatal weight gain patterns and infant birthweight associated with maternal smoking

BACKGROUND

Maternal smoking during pregnancy is recognized as an important and modifiable risk factor for low infant birthweight. The objective of this study was to compare the effects of maternal smoking status on prenatal weight gain and infant birthweight, and to determine if maternal weight gain mediates the effect of smoking cessation on infant birthweight.

METHODS

This prospective study of 341 white, non-Hispanic pregnant smokers, never smokers, and women who stopped smoking during pregnancy used multivariate analysis of variance to evaluate prenatal weight gain patterns. Multiple regression was used to investigate the effects of smoking status and maternal weight gain on infant birthweight.

RESULTS

Women who stopped smoking gained on average 39.68 lb during pregnancy. Smokers gained 32.75 lb, and never smokers gained 34.16 lb. Women who stopped gained significantly more weight than both smokers and never smokers (p = 0.01). Rates of weight gain differed significantly beginning in the second trimester, when women who stopped smoking gained more weight than never smokers (2.57 lb, 99% CI = 0.46, 8.07) and continued during the third trimester, with those who stopped smoking gaining more weight than both smokers (4.31 lb, 99% CI = 1.88, 12.00) and never smokers (1.25 lb, 99% CI = 0.56, 10.49). Infant birthweight differences were significant for women who stopped smoking versus continuing smokers (292 g, 99% CI = 145, 440) and for never smokers versus continuing smokers (253 g, 99% CI = 104, 401). Controlling for baseline maternal body mass index and infant gender, smoking status and weight gain each contributed significantly to infant birthweight (p < 0.001). No evidence of interaction between smoking status and weight gain on infant birthweight was found.

CONCLUSIONS

Maternal smoking status significantly affects prenatal weight gain and infant birthweight, but smoking cessation protects against lower birthweight through mechanisms other than increased maternal weight gain or different weight gain patterns.

Weight gain associated with prenatal smoking cessation in white, non-Hispanic women

OBJECTIVE

Our purpose was to assess the effect of prenatal smoking cessation on maternal weight gain and infant birth weight in women who smoked at least five cigarettes per week.

STUDY DESIGN

This prospective study followed up a sample of white, non-Hispanic pregnant smokers enrolled in three multispecialty clinics. By use of t tests, women quitting smoking before 28 weeks and continuing smokers were compared on total weight gain, Institute of Medicine weight gain categories, and infant birth weight.

RESULTS

Quitters gained 36.6 pounds (SD 14.5) and smokers 28.9 pounds (SD 11.7) (p < 0.001). The relative risk of quitters gaining less than the Institute of Medicine minimum was 0.47 (95% confidence interval 0.27 to 0.81). Quitters also gained more than Institute of Medicine standards (relative risk 1.74, 95% confidence interval 1.21 to 2.51), and they were 3.1 times as likely to be delivered of infants weighing > 4000 gm (95% confidence interval 1.18 to 7.97). The four low-birth-weight babies were born to smokers with low weight pain.

CONCLUSION

In this population smoking cessation is associated with a lower risk of gaining too little by Institute of Medicine standards and also with higher risk of gaining more than the Institute of Medicine standard and having infants weighing > 4000 gm. The clinical significance of these effects needs to be determined in further studies.

A meta-analysis of randomized trials of prenatal smoking cessation interventions

OBJECTIVE

Our purpose was to assess the effect of prenatal smoking interventions on rates of smoking cessation and low birth weight.

STUDY DESIGN

We used a meta-analysis model to compare and summarize smoking cessation and low birth weight outcomes with the risk ratio used as a common metric. We located 11 randomized, controlled trials with objective validation of smoking status; four of these studies also measured rates of low birth weight.

RESULTS

Risk ratios for smoking cessation ranged from 0.9 to 7.1. The combined risk ratio for the homogeneous group of 10 studies was 1.50 (95% confidence interval 1.22 to 1.86) after the outlier study with a risk ratio of 7.1 was excluded. This was a 50% increase in smoking cessation. Low birth weight risk ratios of 0.6 for two studies that achieved a 50% increase in cessation suggested that the incidence of low birth weight was decreased.

CONCLUSION

Prenatal smoking cessation interventions increase rates of smoking cessation during pregnancy, and there is evidence that they reduce the incidence of low birth weight.