Rural Cancer Disparities: Understanding Implications for Breast and Cervical Cancer Diagnoses.

BACKGROUND: Rural populations experience several disparities, influenced by structural-, community-, and individual-level barriers, across the breast and cervical cancer continuum. OBJECTIVES: This study seeks to identify structural-, community-, and individual-level barriers that affect rural populations across the cancer continuum, understand the role of nurses serving rural populations in breast and cervical cancer screening and diagnostics, and provide recommendations for working with rural patients. METHODS: This is a secondary analysis of qualitative interviews conducted with public health nurses serving rural populations. FINDINGS: Emergent themes indicate that rural populations experience barriers that affect disparities across the breast and cervical cancer continuum, including a changing healthcare landscape, access to cancer-focused care, access to insurance, collective poverty, and demographic factors. Nurses working with rural communities can address these disparities as they fulfill multiple roles and responsibilities.

The Effect of Continuous Versus Pregnancy-Only Medicaid Eligibility on Routine Postpartum Care in Wisconsin, 2011-2015.

OBJECTIVE: To compare patterns of routine postpartum health care utilization for women in Wisconsin with continuous Medicaid eligibility versus pregnancy-only Medicaid METHODS: This analysis used Medicaid records and linked infant birth certificates for Medicaid paid births in Wisconsin during 2011-2015 (n = 105,718). We determined if women had continuous or pregnancy-only eligibility from the Medicaid eligibility file. We used a standard list of billing codes to identify if women received routine postpartum care. We examined maternal characteristics and receipt of postpartum care overall and by Medicaid eligibility category. Finally, we used a binomial model to calculate the relationship between Medicaid eligibility category and receipt of postpartum care, adjusted for maternal characteristics. RESULTS: Women with continuous Medicaid had profiles more consistent with low postpartum visit attendance rates (e.g., younger, more likely to use tobacco) than women with pregnancy-only Medicaid. However, after adjusting for maternal characteristics, women with continuous Medicaid eligibility had a postpartum visit rate that was 6 percentage points higher than the rate for women with pregnancy-only Medicaid (RD: 6.27, 95% CI 5.72, 6.82). CONCLUSIONS FOR PRACTICE: Women with pregnancy-only Medicaid were less likely to have received routine postpartum care than women with continuous Medicaid. Medicaid coverage beyond the current guaranteed 60 days postpartum could help provide more women access to postpartum care.

A mixed methods study: Midlife African American women's knowledge, beliefs, and barriers to well-woman visit, flu vaccine, and mammogram use.

African American women (AAW) are particularly at risk for deleterious health outcomes that might be mitigated through increased preventive care use. A mixed methods study that examined relationships between knowledge of, beliefs about, and barriers to well-woman visits, flu vaccines, and mammograms was conducted with midlife AAW who participated in an online survey (n = 124) and in-depth interviews (n = 19). Findings showed that greater knowledge of preventive service recommendations and positive patient-provider relationships were associated with greater preventive service use. Flu vaccines were significantly underused. Study implications inform strategies to increase preventive care utilization among AAW and increase capacities to improve health disparities.

Persisting Gaps in Coverage and Services of Illinois Women Who Acquired Insurance After Implementation of the Affordable Care Act.

OBJECTIVES: Before implementation of the Affordable Care Act, many uninsured women in Illinois received care through safety-net programs. The new law allowed them to acquire health insurance through Medicaid or the Illinois Health Exchange. We examined (1) the health care experiences of such women who previously used a safety-net program and acquired this new coverage and (2) persisting gaps in coverage for breast and cervical cancer services and other health care services. METHODS: We interviewed a stratified random sample of 400 women aged 34-64 in Illinois each year during 2015-2017 (total N = 1200). We used multivariable logistic regression models to determine the association between health insurance status (Illinois Health Exchange vs Medicaid) and past 12-month gaps in coverage (ie, delaying care, not having a recent mammogram, having a medical cost, and having a medical cost not covered) for the 360 women who were former participants of the Illinois Breast and Cervical Cancer Program. We calculated odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for race/ethnicity, age, income, and education. RESULTS: We found no significant differences by health insurance status in the prevalence of delaying preventive, chronic, or sick care; timeliness of the most recent mammogram; and having a major medical cost. However, of women who reported a major medical cost, women with health insurance through the Illinois Health Exchange had a higher prevalence of not having a cost covered than women with Medicaid (adjusted OR = 4.86; 95% CI, 1.48-16.03). CONCLUSIONS: The results of this study suggest that many women who gained health insurance lacked adequate coverage and services. Safety-net programs will likely continue to play an essential role in supporting women as they navigate a complex system.

Adapting to a Shifting Health Care Landscape: Illinois Breast and Cervical Cancer Program Lead Agencies' Perspectives.

Understanding how safety net programs adapt to systemic health care changes is pivotal for creating feasible recommendations for policy implementation. This study characterizes perspectives of Lead Agency (LA) coordinators of the Illinois Breast and Cervical Cancer Program (IBCCP) in response to sociopolitical changes at state and national levels. Our cross-sectional study included 29 semistructured telephone interviews between December 2015 and January 2016. Respondents indicated some changes in the priority population served, changes in referrals and clinical services, and, a continued commitment to IBCCP. Our findings suggest that IBCCP and other safety net programs will need to be flexible to meet the ongoing needs of historically vulnerable populations in a complex, shifting environment. Implications for public health practice and policy include the need to ensure that program personnel are aware of evidence-based strategies to reach different priority populations and are kept abreast of organizational and system changes that may affect referral patterns as well as the need to educate health care providers working with safety net programs about changes in the delivery and coordination of services.

Illinois Breast and Cervical Cancer Program: Implementing Effective Public-Private Partnerships to Assure Population Health.

With the implementation of the Affordable Care Act (ACA), it is essential for the public health sector to elucidate its role with respect to its mission of assuring population health, and to clarify its role with respect to the private health care system. To that end, we examined the value added to the population health enterprise of successful public-private partnerships (PPPs) such as those found in the Illinois Breast and Cervical Cancer Program (IBCCP), the Centers for Disease Control and Prevention's (CDC's) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) in Illinois. Key Informant (KI) interviews focused on IBCCP implementation were conducted with IBCCP lead agency (LA) program coordinators (n = 35/36) in winter 2012-2013. Analysis was conducted using Atlas.ti software. The KI interviews revealed the existence of highly developed PPPs between the IBCCP LAs and individual medical providers and hospitals across Illinois. The data suggest that the small amount of funding provided by IBCCP to each LA in Illinois has been used to build and sustain robust PPPs in the majority of the IBCCP communities. The PPPs developed through the IBCCP can be seen as an unplanned benefit of CDC's investment in breast and cervical health through the NBCCEDP. While the IBCCP/NBCCEDP might be considered a "boutique" categorical program which some may consider no longer necessary as individuals gain insurance under the ACA, the KI data underscore the critical role of public sector dollars, not only to serve individuals and communities directly but also to mobilize the private health care sector to act in partnership with public entities and become advocates for underserved communities.

Relationship between gestational weight gain and birthweight among clients enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Hawaii, 2003-2005.

To investigate the relationship between gestational weight gain (GWG) and birthweight outcomes among a low-income population in Hawaii using GWG recommendations from the 2009 Institute of Medicine (IOM) guidelines. Data were analyzed for 19,130 mother-infant pairs who participated in Hawaii's Special Supplemental Nutrition Program for Women, Infants, and Children from 2003 through 2005. GWG was categorized as inadequate, adequate, or excessive on the basis of GWG charts in the guidelines. Generalized logit models assessed the relationship between mothers' GWG and their child's birthweight category (low birthweight [LBW: < 2,500 g], normal birthweight [2,500 g ≤ BW < 4,000 g], or high birthweight [HBW: ≥ 4,000 g]). Final models were stratified by prepregnancy body mass index (underweight, normal weight, overweight, or obese) and adjusted for maternal age, education, race/ethnicity, smoking status, parity, and marital status. Overall, 62% of the sample had excessive weight gain and 15% had inadequate weight gain. Women with excessive weight gain were more likely to deliver a HBW infant; this relationship was observed for women in all prepregnancy weight categories. Among women with underweight or normal weight prior to pregnancy, those with inadequate weight gain during pregnancy were more likely to deliver a LBW infant. Among the low-income population of Hawaii, women with GWG within the range recommended in the 2009 IOM guidelines had better birthweight outcomes than those with GWG outside the recommended range. Further study is needed to identify optimal GWG goals for women with an obese BMI prior to pregnancy.

The effects of acculturation on healthy lifestyle characteristics among Hispanic fourth-grade children in Texas public schools, 2004-2005.

BACKGROUND: Childhood obesity is a national epidemic that disproportionately affects Hispanic children. Evidence suggests that increased acculturation among this population adversely affects diet and other healthy lifestyle characteristics, leading to higher rates of overweight and obesity. Healthy lifestyle characteristics must be understood in order to prevent or decrease overweight and obesity among Hispanic children. METHODS: Using the School Physical Activity and Nutrition (SPAN) study, we examined cross-sectional data on healthy lifestyle characteristics collected in Texas public schools from Hispanic fourth-grade children in 2004-2005. We calculated adjusted odds ratios and associated confidence intervals using multivariate logistic regression analyses to analyze the association between acculturation and healthy lifestyle characteristics among Spanish-speaking Hispanic children compared to English-speaking Hispanic children. RESULTS: Spanish-speaking Hispanic boys consumed more milk and fruit than English-speaking Hispanic boys (milk: adjusted odds ratio [AOR]: 1.7, p = .02; fruit: AOR: 2.5, p = .0001). The likelihood that Spanish-speaking Hispanic boys and girls did not know that there is a relationship between overweight and health problems were 2 times greater (boys: AOR: 1.7, p = .03; girls: AOR: 2.2, p = .006) than their English-speaking Hispanic counterparts. Likelihood of weight loss attempts was greater among Spanish-speaking Hispanic boys than English-speaking Hispanic boys (AOR: 1.9, p = .04). CONCLUSIONS: Results are mixed. Lower levels of acculturation appear to be associated with both positive and negative healthy lifestyle characteristics, depending on sex. These findings have important implications for school health policies and programs and should be distributed to school administrators.

Changing trends in low birth weight rates among non-Hispanic black infants in the United States, 1991-2004.

We examined trends in low birth weight (LBW, <2,500 g) rates among US singleton non-Hispanic black infants between 1991 and 2004. We conducted Joinpoint regression analyses, using birth certificate data, to describe trends in LBW, moderately LBW (MLBW, 1,500-2,499 g), and very LBW (VLBW, <1,500 g) rates. We then conducted cross-sectional and binomial regression analyses to relate these trends to changes in maternal or obstetric factors. Non-Hispanic black LBW rates declined -7.35% between 1991 and 2001 and then increased +4.23% through 2004. The LBW trends were not uniform across birth weight subcategories. Among MLBW births, the 1991-2001 decease was -10.20%; the 2001-2004 increase was +5.61%. VLBW did not follow this pattern, increasing +3.84% between 1991 and 1999 and then remaining relatively stable through 2004. In adjusted models, the 1991-2001 MLBW rate decrease was associated with changes in first-trimester prenatal care, cigarette smoking, education levels, maternal foreign-born status, and pregnancy weight gain. The 2001-2004 MLBW rate increase was independent of changes in observed maternal demographic characteristics, prenatal care, and obstetric variables. Between 1991 and 2001, progress occurred in reducing MLBW rates among non-Hispanic black infants. This progress was not maintained between 2001 and 2004 nor did it occur for VLBW infants between 1991 and 2004. Observed population changes in maternal socio-demographic and health-related factors were associated with the 1991-2001 decrease, suggesting multiple risk factors need to be simultaneously addressed to reduce non-Hispanic black LBW rates.

Changes in maternal cigarette smoking among pregnant WIC participants in Rhode Island.

OBJECTIVES: To describe the relationship between the timing of entry into the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) among pregnant women in Rhode Island (RI) and changes in maternal cigarette smoking (MCS) during pregnancy. METHODS: MCS data gathered by WIC were analyzed for pregnant women who self-identified as smokers at the onset of pregnancy between the years 2001-2005. Bivariate and multivariate analyses were performed to examine the relationship between timing of WIC entry and both increased and decreased/quit MCS during pregnancy. RESULTS: Self-reports from smokers indicated that 9.5% quit smoking, 24.6% decreased MCS, 26.8% experienced no change, 33.5% increased MCS, and 5.6% attempted to quit MCS but failed during pregnancy. The adjusted odds ratio for smokers with 1st trimester WIC entry and increased MCS was 0.64 (95% CI 0.52, 0.79). Among smokers with 1st trimester PNC entry, the adjusted odds ratio for smokers with 1st trimester WIC entry and decreased/quit MCS was 1.51 (95% CI 1.17, 1.96). CONCLUSIONS: Early WIC entry appears to be associated with improvements in MCS. Participants who entered WIC in the first trimester of pregnancy were less likely to increase smoking during pregnancy, and if they also had first trimester prenatal care, were more likely to decrease/quit smoking compared to those who entered WIC later. Programs that increase the rates of first trimester WIC entry may contribute to lower rates of MCS in the WIC population.