Correlates of experiencing life events just before or during pregnancy.

This study evaluates the prevalence of selected life events around the time of pregnancy, examining changes in the prevalence of these events, and identifying maternal characteristics associated with these events. We used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) to examine 18 stressful life events among women who recently gave birth and to identify maternal characteristics associated with these events. PRAMS is a mail sample survey with telephone follow-up for non-respondents. Sixty-four percent of women experienced at least one event. The prevalence of specific events ranged from 0.4 to 30%. Women who experienced events differed from those who did not. Most notably, women of low socioeconomic status (SES) were much more likely to experience stressful life events. These events were also associated with other demographic and behavioral characteristics after controlling for SES. These results have implications for interpreting studies of stressful life events. The strong associations with SES highlight the importance of controlling for SES in studies of life events and health, and of considering differences in SES when interpreting these studies.

Patterns and predictors of the breast cancer detection methods in women under 45 years of age (United States).

OBJECTIVES: Few studies have examined methods by which breast cancers are detected, and only one study has been published on predictors of those methods. This study examined patterns and predictors of breast cancer detection methods during 1990-1992 among women age 20-44. METHODS: In-person interview and medical record data were obtained during a population-based case-control study of 1619 women newly diagnosed with breast cancer in three areas of the United States (US). RESULTS: Seventy-one percent of the cancers were identified by self-detection, 9% by routine clinical breast exam (CBE), and 20% by routine mammography. Cancers detected by mammography and CBE, but not those detected by breast self-exam, were much more likely to be early-stage. Detection by mammography increased with age, and a history of mammography use was associated with detection by mammography or CBE. Several commonly studied predictors of screening utilization in the US population were associated with CBE detection, but were less clearly related to or unrelated to mammography detection. CONCLUSION: Findings suggest that, during the 1990s in the US, most breast cancers among women under age 45, including those age 40-44, were self-detected. Few factors other than age and prior screening are verified predictors of method of breast cancer detection.

Comparison of telephone sampling and area sampling: response rates and within-household coverage.

Random digit dialing is used frequently in epidemiologic case-control studies to select population-based controls, even when both cases and controls are interviewed face-to-face. However, concerns persist about the potential biases of random digit dialing, particularly given its generally lower response rates. In an Atlanta, Georgia, case-control study of breast cancer among women aged 20-54 years, all of whom were interviewed face-to-face, two statistically independent control groups were compared: those obtained through random digit dialing (n = 652) and those obtained through area probability sampling (n = 640). The household screening rate was significantly higher for the area sample, by 5.5%. Interview response rates were comparable. The telephone sample estimated a significantly larger percentage (by approximately 7%) of households to have no age-eligible women. Both control groups, appropriately weighted, had characteristics similar to US Census demographic characteristics for Atlanta women, except that respondents in both control groups were more educated and more likely to be married. The authors conclude that households contacted through random digit dialing are somewhat less likely to participate in the household screening process, and if they are cooperative, some households may not disclose that age-eligible women reside therein. Investigators need to develop improved methods for screening and enumerating household members in random digit dialing surveys that target a specific subpopulation, such as women.

Implementing the Institute of Medicine report on lesbian health.

The Institute of Medicine (IOM) recently published the report of its committee on lesbian health research priorities, which concluded that there has been little emphasis on and funding for research on the health of lesbians, despite the increased emphasis on women's health research in the 1990s. The report recommended additional research to determine if lesbians are at higher (or lower) risk for certain health problems than other women. It noted significant barriers to conducting lesbian health research, including lack of funding and several methodological issues. The IOM anticipates that the research recommended will benefit other populations as well. Several federal agencies in the Department of Health and Human Services can provide technical expertise and support to implement the report's recommendations, and suggestions are given here. The IOM report legitimizes scientific investigation into lesbian health, which should increase public and private research funding and the number of researchers in this area. A paradigm shift for lesbian health research is on the horizon, and we are grateful to the dedicated cadre of researchers, both published and unpublished, who have pioneered and persisted in this research during the past 25 years.

Functional decline among older adults: comparing a chronic disease cohort and controls when mortality rates are markedly different.

In studies of functional status decline in older persons, the strategy for handling deaths during follow-up may influence policy implications. We compared 301 older ESRD dialysis patients with 322 controls to determine whether functional decline over 3 years among dialysis patients exceeded that of "normal aging." We used two different statistical methods and, for each, compared results when deaths were excluded and then included in the analysis. Dialysis patients incurred a larger follow-up mortality rate and were more impaired at baseline. Findings based on functional transition over time, assessed by a nominal variable, were sensitive to whether or not deaths were included in the analysis. However, findings based on nonparametric methods for an ordinal scale (functional impairment) were not sensitive to whether or not deaths were included in the analysis. Analyzing data with and without deceased subjects may be the most comprehensive approach to comparing two cohorts over time.

Characteristics associated with recent recreational exercise among women 20 to 44 years of age.

Data on 1,501 control women from a multi-center, population-based, case-control study of breast cancer were used to examine characteristics associated with recreational exercise during the year prior to the interview among women 20 to 44 years of age. In a univariate analysis, higher levels of recreational exercise were associated with: higher education; higher family income; white race; previous participation in recreational exercise above the median level at ages 12 to 13 and at age 20; being nulliparous; ever lactating; being a never or past smoker; having a low current Quetelet's index (QI: weight in kilograms divided by height in meters squared); and living in Atlanta or Seattle (compared to New Jersey). In a multiple linear regression model, independent predictors of higher levels of recreational exercise were: participation in higher levels of exercise at 20 years of age; having a low current QI; and never having smoked. Though all women should be encouraged to participate in exercise, these findings identity subgroups of women that may need targeting when developing exercise intervention programs.

Electric blanket use and breast cancer risk among younger women.

To investigate whether use of electric blankets, one of the largest sources of electromagnetic field exposure in the home, is associated with the risk of female breast cancer, the authors analyzed data from a population-based US case-control study. The 2,199 case patients were under age 55 years and had been newly diagnosed with breast cancer between 1990 and 1992. The 2,009 controls were frequency-matched to cases by 5-year age group and geographic area. There was little or no risk associated with ever having used electric blankets, mattress pads, or heated water beds among women under age 45 years (adjusted odds ratio = 1.01, 95% confidence interval 0.86-1.18) or among women aged > or =45 years (adjusted odds ratio = 1.12, 95% confidence interval 0.87-1.43). There was no substantial variation in risk with duration of use; with whether the appliance was used only to warm the bed or used throughout the night; with menopausal status; or with the cases' hormone receptor status or stage of disease. Potential breast cancer risk factors that were associated with electric blanket use did not substantially confound the associations under investigation. These data do not support the hypothesis that electric blanket use increases breast cancer risk among women under age 55 years.

Health-related behaviors of women physicians vs other women in the United States.

OBJECTIVE: To examine the health-related behaviors of women physicians compared with those of other women of high and not high socioeconomic status and with national goals. METHODS: We examined the results of a questionnaire-based survey of a stratified random sample, the Women Physicians' Health Study, and a US telephone survey (Behavioral Risk Factor Surveillance System of the Centers for Disease Control and Prevention, Atlanta, Ga). We analyzed 3 samples of women aged 30 to 70 years: (1) respondents from the Women Physicians' Health Study (n = 4501); (2) respondents from the Behavioral Risk Factor Surveillance System (n = 1316) of the highest socioeconomic status; and (3) all other respondents from the Behavioral Risk Factor Surveillance System (n = 35,361). RESULTS: Women physicians were more likely than other women of high socioeconomic status and even more likely than other women not to smoke. The few physicians (3.7%) who smoked reported consuming fewer cigarettes per day, and physicians who had stopped smoking reported quitting at a younger age than women in the general population. Women physicians were less likely to report abstaining from alcohol, but those who drank reported consuming less alcohol per episode than other women and were less likely to report binging on alcohol than women in the general population. Unlike women in the general population and even other women of high socioeconomic status, women physicians' reported behaviors exceeded national goals for the year 2000 in all examined behaviors and screening habits. CONCLUSIONS: Women physicians report having generally good health habits even when compared with other socioeconomically advantaged women and report exceeding all examined national goals for personal screening practices and other personal health behaviors. Women physicians' behaviors may provide useful standards for other women in the United States.

Cigarette smoking and breast cancer risk among young women (United States).

OBJECTIVES: To evaluate whether heavy cigarette smoking as a teenager or long-term smoking increases breast cancer risk or, alternatively, whether smoking acts as an anti-estrogen and reduces risk. METHODS: Data from a multi-center, population-based, case-control study among women under age 55 were analyzed. RESULTS: Among women under age 45, there was a modest inverse relation with current (OR = 0.82, 95% CI = 0.67, 1.01) but not past (OR = 0.99, 95% CI = 0.81, 1.21) smoking. Odds ratios were decreased for current smokers who began at an early age (0.59 for < or = 15, 95% CI = 0.41, 0.85) or continued for long periods of time (0.70 for >21 years, 95% CI = 0.52, 0.94). In subgroup analyses, reduced odds ratios were observed among current smokers who were ever users of oral contraceptives (0.79, 95% CI = 0.63, 0.98), were in the lowest quartile of adult body size (0.53, 95% CI = 0.34, 0.81), or never or infrequently drank alcohol (0.68, 95% CI = 0.47, 0.98). Among women ages 45-54, there was little evidence for an association with smoking. CONCLUSIONS: These results suggest that breast cancer risk among women under age 45 may be reduced among current smokers who began smoking at an early age, or long-term smokers, but require confirmation from other studies.

Alcohol consumption and breast cancer risk among women under age 45 years.

In a population-based case-control study of women younger than 45 years of age, we obtained a detailed lifetime history of alcohol use to evaluate the effects of drinking during different periods of life in relation to breast cancer risk. This analysis focused on interviews obtained from 1,645 cases and 1,497 controls. Breast cancer risk was not influenced by drinking during the teenage years or early adulthood. Contemporary drinking (that is, average intake during the recent 5-year interval) was directly associated with risk, but the adverse effect of recent drinking was restricted to women who consumed > or = 14 drinks per week [relative risk (RR) = 1.7; 95% confidence interval (CI) = 1.2-2.5]. The effect of alcohol was most pronounced among women with advanced disease. Compared with nondrinkers, the risk estimate associated with recent consumption of > or = 14 drinks per week was 2.4 (95% CI = 1.6-3.8) for women with regional/distant disease. Our data add support to the accumulating evidence that alcohol consumption is associated with increased risk of breast cancer and further indicate that alcohol acts at a late stage in breast carcinogenesis.

Pregnancy planning and pre-conception counseling. The PRAMS Working Group.

OBJECTIVE: To estimate the percentage of women with one or more of four potentially modifiable risks who could have availed themselves of pre-conception counseling. METHODS: We defined pre-conception counseling to be consultation that occurs shortly before a couple attempts conception. Thus, we assumed that to obtain pre-conception counseling, a woman must plan her pregnancy. We used data from a population-based survey of 12,452 new mothers in four states who delivered babies during 1988-1990. Mothers were contacted 3-6 months after delivery and asked about pre-conception behaviors and the planning status of their pregnancies. We estimated the percentage of women who planned their pregnancies and had an indication for pre-conception counseling related to smoking, drinking, being underweight, or delaying initiation of prenatal care. RESULTS: State-specific response rates ranged from 68-84%. Sixty percent of mothers reported that their pregnancies were planned. In general, mothers with unintended pregnancies were more likely to have an indication for pre-conception counseling than mothers with planned pregnancies. Thirty-eight percent of all mothers planned their pregnancies and had one or more indications for pre-conception counseling. An additional 30% had one or more indications for counseling but did not have a planned pregnancy. CONCLUSIONS: Despite the limited range of indications for counseling that we considered, a substantial percentage of women potentially could have used counseling. A similar percentage of women could have benefited from family planning services.

Smoking, pregnancy, and source of prenatal care: results from the Pregnancy Risk Assessment Monitoring System. The Pregnancy Risk Assessment Monitoring System Working Group.

OBJECTIVE: To assess the impact of current smoking intervention efforts and to target future efforts by describing the relationships between maternal smoking, smoking cessation, and source of prenatal care. METHODS: We used population-based data from 6319 mothers who delivered live-born infants during 1988 and 1989 in Maine, Michigan, Oklahoma, and West Virginia. The number of women sampled per state ranged from 1490-2659; state-specific response rates ranged from 66-84%. Analysis weights adjusted for selection probability and non-response. RESULTS: The prevalences of maternal smoking before, during, and after pregnancy among women receiving publicly funded prenatal care were 2.3-3.4 times the comparable prevalences among privately insured women receiving prenatal care from private providers. Although many smokers reduced or quit smoking during pregnancy, most resumed or increased their smoking to nearly pre-pregnancy levels by 3-6 months postpartum. CONCLUSIONS: Interventions should target the very high levels of smoking among the 27% of women receiving publicly funded prenatal care. However, from a population perspective, the greatest potential for reduction in smoking is among patients of private providers, who care for 61% of pre-pregnancy smokers.

Assisted survival, aging, and rehabilitation needs: comparison of older dialysis patients and age-matched peers.

In Western societies a growing number of older persons have their lives extended by medical or surgical intervention. Older persons who suffer kidney failure and are maintained by chronic dialysis therapy are a good example. We compared 349 persons aged 60 years or older, who were on chronic dialysis, with 354 persons similar in age, race, gender, and geographic residence who were not undergoing dialysis. Recent health problems and demographic characteristics were included as control variables in all analyses. Older persons on dialysis reported more functional disability (as measured by ADL-mobility difficulty), less frequent walking for exercise, decreased ability to do the things they would like to do, and lower levels of perceived mastery over their lives. They were also more likely to report a need for health-related aids or services. The residual impairments of disabled elderly persons challenge rehabilitation professionals to address quality of life issues.