The Development of a Team-Based, Hybrid Inter-university Graduate Certificate Program Focused on Maternal Child Health Professionals

Introduction

Pregnancy, childbirth, and child well-being are identified by Healthy People 2030 as priority topics for improving the health of all Americans. New Mexico is the fifth largest state geographically with most of the state’s 33 counties considered rural or frontier. Accessing health care services is challenging in this resource-poor environment. The need to provide maternal and child health (MCH) education in the state was the impetus for developing a graduate certificate in maternal and child public health.

Methods

The hybrid MCH graduate certificate engaged professionals in formal training that included a public health approach to addressing MCH issues in the state’s diverse communities. Grant funds paid for the tuition, books and travel for students providing an opportunity to individuals who otherwise could not have pursued graduate education and professional development.

Results

Over a 4-year period, two cohorts were recruited, educated, and evaluated. The evaluations reflected an increase in competency knowledge scores for all students.

Discussion

This model of MCH education was successful at delivering public health graduate education to MCH practitioners and increasing their knowledge and skills. Listening to students and communities as to what their MCH public health needs are and responding with a flexible educational model provided individuals with information and tools that could be used to improve maternal and child health and reduce health disparities in rural, tribal, and underserved communities.

The excess costs of breast cancer health care in Hispanic and non-Hispanic female members of a managed care organization

The differences in costs for health care services between women with breast cancer and those without were estimated for Hispanic and non-Hispanic members of a managed care organization. A total of 317 cases of breast cancer and 949 controls were selected using a comprehensive patient database. All health care costs for the 4-12 months prior to the case's diagnosis and for the 12 months following the case's diagnosis were obtained. Costs were defined as charges to the health plan. Mean differences in total health care costs between cases and controls were predicted using Tobit models for 4-12 months prior to diagnosis and the year after diagnosis by age group. Compared to controls, women diagnosed with in situ breast cancers in all age groups had significantly higher health care costs 4-12 months prior to diagnosis. For women under 50 years of age, the difference in costs for cases compared to controls 12 months after diagnosis was almost three times greater for women with regional/distant disease ($17,093 +/- $1,559) compared to in situ disease ($5,089 +/- $1,050). For women in the two other age groups (50-70 years and over 70 years), the difference was over twice as great for those with regional/distant disease compared to those with in situ disease. Mean differences between cases and controls in health care costs 12 months after diagnosis were similar for Hispanic and non-Hispanic women for all stages of disease.

Mammography utilization after a benign breast biopsy among Hispanic and non-Hispanic women

BACKGROUND

In spite of the effectiveness of mammography screening for early detection of breast carcinoma, the use of screening mammography varies widely across racial and ethnic groups. Recently, concerns have been raised about the potential adverse effect a benign breast biopsy may have on subsequent mammography utilization, including subsequent use among minority women.

METHODS

Computerized health care claims data for 1991 through 1997 from a managed care organization were used to compare mammography use among Hispanic and non-Hispanic women who had had a mammogram followed by an incisional or excisional benign breast biopsy to women who had had a mammogram and no biopsy. Through survival analysis methods, the time-to-next mammogram was compared among these three groups.

RESULTS

The sample included 693 (3.2%) and 289 (1.3%) women who had had a mammogram followed by an incisional biopsy or an excisional biopsy, respectively, and 20,540 (95.4%) women who had had a mammogram and no biopsy. Both Hispanic and non-Hispanic women with a biopsy returned sooner for subsequent mammograms than women without a biopsy (P < 0.0001). Hispanic women without a biopsy returned later than non-Hispanic women without a biopsy (P < 0.0001). However, Hispanic women with an excisional biopsy returned sooner than non-Hispanic women (P < 0.05).

CONCLUSIONS

Within a managed care organization, both Hispanic and non-Hispanic women who had had a mammogram followed by a benign breast biopsy returned sooner for a subsequent mammogram than women who had had a mammogram and no biopsy. However, ethnic differences in time-to-next mammogram were observed for women without a biopsy and those with an excisional biopsy. Hispanic women without a biopsy returned later for a subsequent mammogram than non-Hispanic women in similar groups, but those with an excisional biopsy returned sooner.

Health indicators and intimate partner violence among women who are members of a managed care organization

BACKGROUND

There have been no population-based studies estimating the prevalence of intimate partner violence (IPV) in an insured population. There is also little information on how well routinely collected health status information predicts IPV risk. Many women now obtain health care from providers who are members of a managed care organization (MCO). To justify efforts to routinely screen for IPV, it is essential to know the prevalence of IPV in this growing population and to identify correlates of IPV among female MCO members.

METHODS

A telephone survey with questions on health status, behavioral risk factors, preventive services use, and the Conflict Tactics Scale was completed by 2,415 female members of a New Mexico MCO.

RESULTS

Overall, 13.5% of respondents reported experiencing major verbal aggression and 6.7% reported experiencing physical aggression. Younger age, degree of sadness, and inability to handle stress, and a perception of a poorer general health status were significantly associated with major verbal aggression. Race/ethnicity, degree of sadness, and average number of drinks consumed at one sitting were significantly associated with physical aggression.

CONCLUSIONS

There is a low but important annual prevalence of IPV among female members of a MCO that occurs across all variables studied. This information is needed to develop appropriate screening protocols and interventions in this population.

Mammography screening and breast cancer tumor size in female members of a managed care organization

A study of temporal trends in mammography screening and changes in stage of disease at diagnosis was conducted among Hispanic and non-Hispanic white female members of the Lovelace Health Plan, Flexcare Plan, and Lovelace Senior Plan/Senior Options (LHP), a managed care organization. Two-year screening rates for female members ages 50-74 years were calculated for 1989-1996. From 1989-1996, mammography screening rates for non-Hispanic white female members increased from 65.5 to 71.6%, although this was not a statistically significant increase. Screening rates for Hispanic female members also increased from 50.6 to 62.7%, but they were significantly lower than for non-Hispanic white women. All breast cancers occurring among LHP female members ages 40-74 years were also identified for this same time period. A logistic regression model adjusting for age, year of diagnosis, ethnicity, and duration of enrollment prior to diagnosis found that statistically significant predictors of more advanced stage of disease at diagnosis included young age, diagnosis after 1991 for non-Hispanic white women, and diagnosis prior to 1992 for Hispanic women. Longer duration of enrollment prior to diagnosis was predictive of lower stage of disease, but the odds ratio was not statistically significant. For the time period 1992-1996, Hispanic women with breast cancer were more than twice as likely to have advanced stage of breast cancer compared with non-Hispanic white women (odds ratio, 2.12).

HIV testing among men who have sex with men--results of a telephone survey

BACKGROUND

This article describes the testing behavior for human immunodeficiency virus (HIV) antibody among an urban population of men who have sex with men (MSM) and the reasons given for not being tested for HIV.

METHODS

A random digit dialing telephone survey of men living in selected neighborhoods of Seattle, Washington, was conducted from June through August 1992.

RESULTS

Of 603 MSM interviewed, 82% had ever been tested for HIV; 19% of tested men were seropositive. MSM who were older, nonwhite, with lower income, or not currently sexually active were less likely to have been tested. Among nontesters, 57% believed their risk of infection was too low to justify testing; 52% said they had not tested due to fear of learning the result. Testers and nontesters had similar rates of unprotected sexual behavior.

CONCLUSIONS

Most MSM who had not been tested for HIV believed they were not at risk of infection and/or were fearful of learning the result. To increase the proportion of MSM who test, public health agencies may need to emphasize that unexpected infection does occur and that new therapies are available for those testing positive. Innovative programs may be necessary to reach those who have not yet decided to be tested.

Breast cancer survival among New Mexico Hispanic, American Indian, and non-Hispanic white women (1973-1992)

A study of breast cancer survival was conducted among New Mexico Hispanic and non-Hispanic white women and New Mexico and Arizona American Indian women diagnosed between 1973 and 1992. The goals were to determine whether, after adjusting for first treatment and the extent of disease at diagnosis, American Indian and Hispanic women had poorer survival than non-Hispanic whites and, if survival had improved over time, whether comparable improvements had been made for the three racial/ethnic groups. Five-year relative survival rates were calculated, and a Cox proportional hazards model was constructed to compare survival between races/ethnicities, adjusting for first treatment and the extent of disease at diagnosis. Findings indicate that during 1983-1992, breast cancer was more commonly detected at a local stage for all three groups compared to 1973-1982. Five-year relative survival improved for non-Hispanic white and American Indian women with local or regional disease, but the improvement was statistically significant only for non-Hispanic white women and for American Indian women with local disease. Despite earlier stages at diagnosis, Hispanic females showed less improvement in overall or stage-specific survival than non-Hispanic whites. The Cox model indicated that American Indian women experienced poorer survival than non-Hispanic whites during both time periods. Survival of Hispanic women with breast cancer was comparable to non-Hispanic whites during 1973-1982 but was significantly worse during 1983-1992. The significance of this lower survival is amplified by increasing breast cancer incidence among New Mexico Hispanics and American Indians.

Mortality in a cohort of orchard workers exposed to lead arsenate pesticide spray

During the period from 1890 to 1940, lead arsenate was the major pesticide used in apple orchards to control the coddling moth. In the Wenatchee area of Washington State, lead arsenate spray was used for longer periods and in larger quantities than in other areas of the United States. In 1938, a cohort of 1,231 people who lived in this area was selected for a study to determine the effects of exposure to lead arsenate spray and residue. This same cohort was re-examined to determine whether there was excess mortality that could be attributed to the lead arsenate exposure. Three levels of exposure (i.e., orchardist, intermediate, consumer) were defined, based upon the use of lead arsenate pesticide spray before and during the 1938 apple growing season. Age-adjusted hazard ratios for all causes of mortality were elevated for both male orchardists and male intermediates. The only significantly increased age-adjusted hazard ratio (1.94) was heart disease in male intermediates. No significantly elevated age-adjusted hazard ratios were observed for women in any exposure group. The lack of evidence that supported an increase in mortality from respiratory cancer in this cohort may have resulted from the lower cumulative concentration of arsenic exposure, the type of arsenical compound, and the small number of study subjects.

History of smoking from the Washington State death certificate

Beginning in 1988, a question added to the Washington State death certificate asked whether the decedent had smoked during the last 15 years of life. We analyzed death certificate data to evaluate the effectiveness of this question in identifying groups with high smoking rates and occupations with high rates of respiratory disease death among nonsmokers. We obtained statistical death certificate data from the Washington State Department of Health for resident deaths occurring between 1988 and 1991. Analyses included information on age, sex, race/ethnicity, marital status, underlying cause of death, high school graduation, smoking during the last 15 years of life, and occupation. Based on logistic regression analysis, we found that male sex, youth, divorced status, or death from lung cancer, chronic obstructive lung disease, or ischemic heart disease predicted a higher risk of smoking during the last 15 years of life. Hispanic ethnicity, single or widowed status, high school graduation, or death from breast cancer, diabetes, motor vehicle accidents, other accidents, or homicide predicted a lower risk of smoking. In farming occupations, there was an excess number of chronic obstructive lung disease deaths among nonsmokers. Findings from this study suggest that patterns of smoking during the last 15 years of life among decedents can provide useful public health surveillance information. The collection of risk factor information, such as smoking, should be recommended for the U.S. standard death certificate. Questions on smoking should be both simple and answerable by informants who may not have known the decedent for a lifetime. Additional studies on the accuracy of smoking history from the death certificate should be conducted.

Correctness of racial coding of American Indians and Alaska Natives on the Washington State death certificate

Underestimation of death rates for specific races can obscure health problems and impair the ability of public programs to prevent premature death and disability. For accurate race-specific death rates, the racial classification of both the population at risk and the decreased population must be accurately ascertained. However, studies suggest that the American Indian (AI) and Alaska Native (AN) races may be not be accurately recorded on the death certificate. We performed a computerized linkage between the Indian Health Service (IHS) patient registry and the 1985-1990 computerized Washington State death certificate data. The deceased was correctly identified as AI or AN on the death certificate for 1,088 (87.2%) of 1,248 matched deaths. The majority (93%) of deceased persons identified on the death certificate as not AI or AN were listed as white. The percentage of American Indian ancestry was strongly associated with correct racial classification on the death certificate (P < .001). Birth in Washington State, membership in a large Washington State tribe, and death from an alcohol condition independently added to the likelihood of correct AI or AN racial classification. Persons who died from cancer were significantly less likely to be correctly coded as AI or AN on the death certificate.

Smoking prevalence during pregnancy for women who are and women who are not Medicaid-funded

Maternal smoking has been related to a number of adverse pregnancy outcomes. Although maternal smoking prevalence has decreased over time, certain populations have retained a high smoking prevalence and remain at high risk for adverse pregnancy outcomes. This study used the Washington State First Steps Program Database to estimate the difference in maternal smoking prevalence between mothers whose prenatal or delivery care was Medicaid-funded and mothers whose care was not Medicaid-funded. We evaluated differences in maternal smoking prevalence between these two groups by marital status, race, adequacy of prenatal care, and age. Among the Medicaid-funded mothers, the age-adjusted maternal smoking prevalence was 44.4% versus 16.3% for those not Medicaid-funded. Among married Medicaid-funded mothers, the smoking prevalence was 2.6 times higher in whites, 1.4 times higher in blacks, and 1.8 times higher in American Indians than for married mothers not funded by Medicaid. Among single Medicaid-funded mothers, the rate was 1.4 times higher in whites and 1.7 times higher in blacks. Differences in smoking prevalence were most apparent among older mothers. For single white and single black mothers, the smoking prevalence increased with increasing maternal age among both Medicaid-funded and other women. Adequacy of prenatal care also influences smoking prevalence. For white and black mothers, the maternal smoking prevalence was lower for those receiving adequate prenatal care than for mothers of the same race who received inadequate prenatal care. The increased maternal smoking prevalence in older single mothers and the higher maternal smoking prevalence in women with Medicaid-funded deliveries suggest that infants born to these mothers may be particularly susceptible to smoking-related health effects.

Physical injury risk versus risk from hazardous waste remediation: a case history

This study was conducted to estimate the transportation risks associated with the removal of contaminated soils near the ASARCO copper smelter in Ruston, Washington. Three remediation options involving removal of differing amounts of soil were considered. The risks of death, disabling, and nondisabling injury were estimated. Under the scenario requiring the greatest soil removal, 3.62 disabling injuries, 14.46 possibly disabling injuries, and 0.67 deaths are expected to result from transporting the contaminated soil to an approved hazardous waste disposal facility. If the contaminated soil is not removed, the U.S. Environmental Protection Agency estimates that 2 arsenic-related skin cancers per 1000 lifetimes for exposed persons will occur.

Smoking prevalence of pregnant women compared to women in the general population of Washington State

We used two readily available sources of information to identify subgroups of pregnant Washington State women with high smoking rates. We compared smoking rates in pregnant women and women in general using information from the Washington State birth certificate collection system and the Washington State Behavioral Risk Factor Surveillance System. Smoking rates are substantially higher in young mothers 18-24 years of age than in comparable age cohorts in the general population of women in the state. In contrast, mothers 25 years of age and older smoke at lower rates than their age cohort in the general population. For multiparous women of all ages, smoking prevalence is related to age at first birth. Married women, whether pregnant or not, smoked less than unmarried women.

Evaluation of a follow-up system in a county health department's immunization clinic

We designed a pilot follow-up system using two mailed reminders and evaluated it for use in the immunization clinic of a relatively large county health department in Washington State. Compliance with the recommended interval for DTP immunizations increased by 33.9% in the group of children receiving two postcard reminders compared to the control group. Over half of the respondents (52%) in the control group and 28% in the intervention group reported that transportation barriers and clinic problems prevented their return.

Trends in teenage smoking during pregnancy. Washington State: 1984 through 1988

Smoking rates in the United States have decreased since 1963, but this trend is less apparent in adolescents, especially girls. Using data on birth certificates from 1984 through 1988, we analyzed smoking trends during pregnancy in teenagers in Washington State. There was a small but significant increase in the overall smoking prevalence during pregnancy between 1984 (32%) and 1988 (37%). Smoking rates varied by mother's age, race and ethnicity, marital status, and prenatal care. Whites had the highest smoking prevalence, and native Americans showed the largest increase in smoking prevalence over time. In the 5 years studied, unmarried pregnant teenagers had a smoking prevalence of 42.8%, compared with a rate of 31.7% in married teenagers. Compared with other studies of smoking rates in nonpregnant teenagers, pregnant teenagers in Washington State had a much higher smoking prevalence than their nonpregnant peers, and the differences between these two groups did not appear to diminish over time. This study suggests that there is little movement toward meeting the 1990 Health Objectives for the Nation regarding smoking in Washington State teenagers who become pregnant.