California Pregnancy-Associated Mortality Review: mixed methods approach for improved case identification, cause of death analyses and translation of findings.

After several decades of declining rates, maternal mortality climbed in California from a three-year moving average of 9.4 deaths per 100,000 live births in 1999-2001 to a high of 14.0 deaths per 100,000 live births in 2006-2008 (p < 0.001). The Maternal, Child and Adolescent Health Division of the California Department of Public Health developed a mixed method approach to identify and investigate maternal deaths to inform prevention strategies. This paper describes the methodology of the California Pregnancy-Associated Mortality Review (CA-PAMR) and its advantages for improved surveillance, cause of death analysis, and translation of findings. From 2002 to 2004, 1,598,792 live births occurred in California and 555 women died while pregnant or within one year of pregnancy. A screening algorithm identified cases for review that were likely to be pregnancy-related. Medical records were then abstracted and reviewed by a multidisciplinary committee to determine cause of death, contributing factors, and opportunities for quality improvement. Mixed methods were used to analyze, synthesize and translate Committee recommendations for improved care. Of 211 cases selected for review, 145 deaths were determined to be pregnancy-related. CA-PAMR methods corrected misclassification of cases and more accurately identified the leading causes of death. Cardiovascular disease emerged as the leading cause of pregnancy-related deaths (20%), and African-American women were disproportionately represented among cardiovascular deaths. Overall, the chance to prevent the fatal outcome appeared good or strong in 40% of cases reviewed. The CA-PAMR methodology resulted in additional case finding, improved accuracy of the causes of pregnancy-related deaths, and evidence to guide development of prevention and quality improvement efforts.

Families with Young Children in California: Findings from the California Health Interview Survey, 2011-2014, by Geography and Home Language.

Using data from the California Health Interview Survey (CHIS) for the years 2011-2014, this report presents findings on families with children ages 0-5 years. It breaks down differences between urban, suburban, and rural families, and it highlights the characteristics of families who speak a language other than English in the home. As more than half of families with young children in California speak a language other than English in the home, the characteristics of dual language households are highlighted. In 1998, California passed the California Children and Families Act to improve development for children from the prenatal stage to five years of age. One goal of this ongoing commitment is to expand our understanding of the social and physical environments that can impact a child's well-being and school readiness.

Community-based participatory research in the California Health Interview Survey.

INTRODUCTION: The California Health Interview Survey, the largest state health survey in the United States, uses community-based participatory research principles to develop each cycle. Other large-scale health surveys rarely include participatory research approaches. Every 2 years, the California Health Interview Survey generates state and local population-based data on health insurance coverage, access to health care, chronic disease prevalence and management, health behaviors and disease prevention, and other health issues in California. The survey is used for policy and program development, advocacy, and research. METHODS: The development of the California Health Interview Survey involves more than 145 people from more than 60 state and local policymaking bodies, public health agencies, advocacy groups, research organizations, and health care organizations. They participate as volunteers in an advisory board, on technical advisory committees, and in work groups that interact with California Health Interview Survey research staff in an accountable advisory process that shapes survey topics, measures, and sample design and determines languages selected for translation. Survey results and data are provided to the communities involved in the survey. RESULTS: California Health Interview Survey data have been widely used by local, state, and national public health leaders, policymakers, advocates, and researchers to improve access to health insurance and health care services and to develop and target prevention programs for obesity and chronic illnesses. CONCLUSION: The California Health Interview Survey participatory research model has been an effective approach to planning and implementing a health survey and should be considered by developers of other large health surveys.

Ten-year trends in the health of young children in California: 2003 to 2011-2012.

This policy brief presents 10-year trends in several key health and wellness indicators for children ages 0-5 in California. These indicators are health insurance coverage; source of medical care; dental visits; overweight-for-age; parents singing and reading to their child and going out with the child; and preschool attendance. The data are from the California Health Interview Survey (CHIS), the largest state health survey in the U.S. The survey gathers information on a range of health behaviors and health conditions, as well as on access to health care among children, adolescents, and adults in California. A number of these key indicators are compared by income and by racial/ethnic group. This policy brief covers the years 2003 to 2011-2012, a period in which public health efforts for children focused on childhood obesity and improved nutrition, access to low-cost and free dental services, and the expansion of children's health insurance programs. CHIS data show improvement in health insurance coverage and access to dental services for low-income children over the 10-year period. However, the percentage of children who were overweight for their age remained unchanged among those in households with incomes below 200 percent of the federal poverty level (FPL). In terms of measures associated with school readiness, preschool attendance dropped overall between 2003 and 2011-2012, but the proportions of parents who sang, read, and went out with their children every day increased significantly during the 10-year period.

Willingness to have unprotected sex.

Little is known about people's willingness to engage in sex without protection from unwanted pregnancy. This study surveyed 1,497 women and men at 75 clinics and physician offices across California after their reproductive health care visits in late 2007 and early 2008. When asked if they would have sex without contraception, 30% said definitively that yes, they would have unprotected sex, and 20% indicated they would "sometimes" or "maybe" engage in unprotected sex. In multivariate models, compared to non-Latino White respondents, Latinos who responded to the survey in English were 52% more likely and African Americans were 75% more likely to report willingness to have unprotected intercourse. Wanting a child within the next three years was associated with increased willingness to have unprotected sex. Age, gender, parity, and relationship status were not significant in multivariate models. A considerable proportion of women and men may be willing to have unprotected sex, even with access to subsidized contraceptive services and even when recently counseled about birth control. The dominant behavioral models of contraceptive use need to acknowledge the widespread likelihood of occasional unprotected sex, even among people motivated to usually use contraceptives. Findings underscore the need to make contraceptive methods accessible, easy to use, and even pleasurable.

Children's exposure to secondhand smoke: nearly one million affected in California.

Despite the steady decline of smoking rates in California, over 200,000 children under age 12 live in homes where smoking is allowed, and another 742,000 live with an adult or adolescent smoker. Significant differences in children's exposure to tobacco smoke and risk of exposure are found by race/ethnicity, geographic regions within the state and by poverty level. African-American children were found to have a significantly higher rate of exposure than other racial and ethnic groups, while children in the Northern/Sierra and San Joaquin Valley regions were at the highest risk of exposure to secondhand smoke. Children living in lower-income households were also at higher risk. These findings can aid strategies to decrease children's exposure to tobacco smoke in the home through targeted public health messages and outreach to those enrolled in public programs.

The link between intimate partner violence, substance abuse and mental health in California.

This policy brief presents findings on the linkages between intimate partner violence (IPV), emotional health and substance use among adults ages 18-65 in California. Among the 3.5 million Californians who have ever been victimized by IPV as adults, over half a million report serious psychological distress (SPD) in the past year. Almost half of all adult IPV victims indicate that their partner was under the influence of alcohol or other drugs during the most recent incident. Two-fifths of adult IPV victims report past-year binge drinking and 7% report daily or weekly binge drinking. One in three IPV victims expressed a need for mental health, alcohol or other drug (AOD) services and almost one-fourth used mental health or AOD services during the past year. These disturbing findings can aid strategies to identify, intervene with and assist IPV victims who experience emotional and/or substance use problems.