Women's Health Alliance Intervention Study: increasing community breast and cervical cancer screening.

The Women's Health Alliance Intervention Study is a quasi-experimental intervention designed to test if county-based coalitions can increase breast and cervical cancer screening compliance among women aged 40 years and older living in rural communities. A number of interventions were designed and implemented by coalitions in four counties in north-central Wisconsin during a 2-year period. Four control counties in southwestern Wisconsin were identified for comparison. Judging from the results of this study, community-based intervention efforts can increase breast and cervical cancer screening compliance significantly among women living in rural communities.

Women's Health Alliance Intervention Study: description of a breast and cervical cancer screening program.

The Women's Health Alliance Intervention Study is a community-based intervention study designed to determine if county-based coalitions can increase breast and cervical cancer screening rates among women aged 40 and older in four rural Wisconsin counties. This article describes the intervention process and demonstrates the feasibility of rural volunteer coalitions to promote breast and cervical cancer screening in communities. An accompanying article in this issue describes the effectiveness of these interventions.

Serum cholesterol concentrations and all-cause mortality in older people.

OBJECTIVE: To study the impact of serum cholesterol concentrations on the total risk of mortality in older people. DESIGN: Retrospective cohort study with a follow-up of 8-10 years. SUBJECTS: A total of 989 subjects (367 men and 622 women) aged 65 and over, living in the Marshfield Epidemiologic Study Area at the time of their first complete serum lipid assessment. METHODS: We calculated sex-specific mean levels of serum total cholesterol, low-density lipoprotein, high-density lipoprotein and triglycerides, and the ratio of total cholesterol to high-density lipoprotein, for subjects who died of all causes and for those who survived to the end of follow-up, with adjustment for relevant covariates. We obtained estimates of the risk factor-adjusted sex-specific relative risk for all-cause mortality with approximate quartiles of serum cholesterol concentrations by proportional hazards regression models. We also evaluated the possible combined effects of age, sex and cholesterol on all-cause mortality. RESULTS: A high level of high-density lipoprotein was significantly associated with a low total risk of mortality in older men. Conversely, an elevated ratio of total cholesterol to high-density lipoprotein was directly related to an increased total risk of mortality in older men. Age and high-density lipoprotein level had a significant synergistic effect on all-cause mortality for the elderly men. We found little or no association in women between all-cause mortality and any of the lipid measures studied. CONCLUSIONS: An increased ratio of total cholesterol to high-density lipoprotein appears to be associated with an increase in risk for all-cause mortality in men aged 65 and over, while an elevated level of high-density lipoprotein, considered alone, seems to be protective against mortality from all causes in men aged 65-74 years, but this effect diminishes over the age of 75.

Breast cancer screening and family history among rural women in Wisconsin.

This study examines the relationship between family history of breast cancer and current compliance with mammography screening guidelines. A random telephone survey of women age 40 or older living in rural Wisconsin (N = 2398) was conducted to determine mammography screening knowledge, family history of breast cancer, attitudes, intentions, physician recommendation, and compliance with screening guidelines. Compared with women without a family history of breast cancer, women with a family history were significantly more likely to demonstrate correct knowledge (p = 0. 01); express intentions in compliance with recommended screening guidelines (p < 0.001); report having been advised by a physician to obtain a mammogram (p < 0.001); and be in current compliance with mammography screening guidelines (p < 0.001). Results of simultaneous and individual logistic regression suggest that the effects of family history on compliance with screening guidelines are directly mediated through the combination of women's knowledge, women's intentions, and physician recommendation. Thus, programs to increase compliance with mammography screening guidelines should address both women and providers.

Cervical cancer screening among women with and without hysterectomies.

OBJECTIVE: To compare the rate of Papanicolaou testing in a population-based sample of women with medical documentation of 1) total hysterectomy for benign conditions, 2) total hysterectomy for malignant conditions, and 3) hysterectomy with cervix intact to rates among women who had not had a hysterectomy. METHODS: The Marshfield Epidemiologic Study Area was used to identify a retrospective cohort of women with hysterectomies age-matched to women without hysterectomies. This study compares the Papanicolaou test rate per year (outcome) by hysterectomy status (exposure) for women with total hysterectomy for benign reasons (n=197), total hysterectomy for malignancy (n=75), supracervical hysterectomy (n=43), and no hysterectomy (n=315). RESULTS: Compared with women who did not have a hysterectomy (nonexposed), women with a hysterectomy (exposed) for benign reasons had significantly fewer Papanicolaou tests; on average, one less test every 3 years (mean difference=-0.34 tests/year, P < .001). Contrary to this, women with a malignancy-related hysterectomy had significantly more tests than their nonexposed counterparts (mean difference=0.87 tests/year, P < .001); nearly one additional test per year. Finally, women with supracervical hysterectomies had the same rate of testing as their nonexposed counterparts (mean difference=-0.03 tests/year, P=.62); on average, one test every 2.5 years. CONCLUSION: This study demonstrates that Papanicolaou testing rates vary by type and reason for hysterectomy. Women with hysterectomies for benign reasons may be receiving from two to three times as many tests as needed. Notably, women with intact cervices following hysterectomy have similar testing rates (one every 2.5 years) as women without hysterectomies. This has direct implications for leaving a woman's cervix intact given normal cytology at the time of hysterectomy.

Psychosocial risk factors for coronary heart disease in women.

The area of psychosocial risk factors for heart disease has not been as thoroughly studied in women as it has been in men. Findings from various studies are often conflicting or nonconclusive. This article summarizes the salient findings from various studies of social, behavioral, and psychological risk factors in women and delineates potential avenues for future research.

Epidemiologic research in an integrated regional medical care system: the Marshfield Epidemiologic Study Area.

To capitalize on Marshfield Clinic's advantages for population-based health research, we developed the Marshfield Epidemiologic Study Area (MESA). Marshfield Clinic is an integrated system consisting of a large multispecialty clinic and 23 affiliated clinics. Clinic physicians provide virtually all of the medical care, both inpatient and outpatient, for residents of the area. MESA consists of 14 ZIP codes in which over 95% of the 50,000 residents and most significant health events are captured in Marshfield Clinic databases, including all deaths, 94% of hospital discharges, and 92% of medical outpatient visits. MESA exemplifies the research potential of integrated medical care systems and the efforts required to realize that potential. Because it is representative of a defined population and provides an unselected sample of patients, MESA is well suited for epidemiologic research and research elucidating the clinical spectrum and natural history of diseases and the effectiveness of treatment.

Poverty and death in the United States.

The authors conducted a survival analysis to determine the effect of poverty on mortality in a national sample of blacks and whites, 25 to 74 years of age (the first National Health and Nutrition Examination Survey (NHANES-1) and NHANES-1 Epidemiologic Follow up Study). They estimated the proportion of mortality associated with poverty during 1971-1984 and in 1991 by calculating population attributable risk and assessed confounding by major known risk factors (e.g., smoking, cholesterol levels, and physical inactivity). In 1973, 6.0 percent of U.S. mortality among black and white persons 25 to 74 years of age was attributable to poverty; in 1991, the proportion was 5.9 percent. In 1991, rates of mortality attributable to poverty were lowest for white women, 2.2 times as high for white men, 8.6 times as high for black men, and 3.6 times as high for black women. Adjustment for all these potential confounders combined had little effect on the hazard ratio among men, but reduced the effect of poverty on mortality among women by 42 percent. The proportion of mortality attributable to poverty among U.S. black and white adults has changed only minimally in recent decades. The effect of poverty on mortality must be largely explained by conditions other than commonly recognized risk factors.