Intervention to improve follow-up for abnormal Papanicolaou tests: a randomized clinical trial.

OBJECTIVE: To evaluate the effect of a theory-based, culturally targeted intervention on adherence to follow-up among low-income and minority women who experience an abnormal Pap test. METHOD: 5,049 women were enrolled and underwent Pap testing. Of these, 378 had an abnormal result and 341 (90%) were randomized to one of three groups to receive their results: Intervention (I): culturally targeted behavioral and normative beliefs + knowledge/skills + salience + environmental constraints/barriers counseling; Active Control (AC): nontargeted behavioral and normative beliefs + knowledge/skills + salience + environmental constraints/barriers counseling; or Standard Care Only (SCO). The primary outcome was attendance at the initial follow-up appointment. Secondary outcomes included delay in care, completion of care at 18 months, state anxiety (STAI Y-6), depressive symptoms (CES-D), and distress (CDDQ). Anxiety was assessed at enrollment, notification of results, and 7-14 days later with the CDDQ and CES-D. RESULTS: 299 women were included in intent-to-treat analyses. Adherence rates were 60% (I), 54% (AC), and 58% (SCO), p = .73. Completion rates were 39% (I) and 35% in the AC and SCO groups, p = .77. Delay in care (in days) was (M ± SD): 58 ± 75 (I), 69 ± 72 (AC), and 54 ± 75 (SCO), p = .75. Adherence was associated with higher anxiety at notification, p < .01 and delay < 90 days (vs. 90+) was associated with greater perceived personal responsibility, p < .05. Women not completing their care (vs. those who did) had higher CES-D scores at enrollment, p < .05. CONCLUSIONS: A theory-based, culturally targeted message was not more effective than a nontargeted message or standard care in improving behavior.

The effect of acculturation on progesterone/estriol ratios and preterm birth in Hispanics.

OBJECTIVE: To examine the Hispanic acculturation paradox by identifying the effect of acculturation on serum progesterone and estriol levels, the progesterone/estriol ratio, and preterm birth. METHODS: We used an observational, prospective design with 468 self-identified, low-income, pregnant Hispanic women. We used the Language Proficiency Subscale (from the Bidimensional Acculturation Scale for Hispanics) to measure acculturation. We measured progesterone and estriol in maternal serum at 22-24 weeks of pregnancy. We defined preterm birth as birth before 37 weeks of gestation. Statistical analysis was by Wilcox-Mann-Whitney and Kruskal-Wallis tests, analysis of variance, t tests, logistic regression, and structural equation modeling. RESULTS: English proficiency had an adjusted odds ratio of 4.03 (95% confidence interval 1.44-11.25), P<.001, and the lowest quartile of the progesterone/estriol ratio had an adjusted odds ratio of 2.93 (95% confidence interval 1.25-6.89), P<.001, to predict preterm birth. English proficiency was associated with a decrease in progesterone/estriol ratio and an increase in preterm birth. In structural equation modeling, the progesterone/estriol ratio mediated the relationship between acculturation and preterm birth. CONCLUSION: Hispanic woman have four times the risk of a preterm birth if they are more acculturated (ie, proficient in English). These findings demonstrate another possible aspect of obstetric risk, that of acculturation. Further refinement of the risk of acculturation is essential to clarify how we can adjust our clinical care to prevent increasing preterm birth with the increasing Hispanic population. LEVEL OF EVIDENCE: III.

A patient-centered health care delivery system by a university obstetrics and gynecology department.

At the University of Texas Medical Branch at Galveston, we developed an off-site clinic system that offers a wide array of services to low-income women and their infants over a large geographic area. These clinics strove toward cultural sensitivity and competency. This patient-centered approach was well accepted and appreciated by our patients. The clinics offered unique, value-added services including combined location with other needed services, on-site laboratory and antepartum testing, the option for delivery at the University of Texas Medical Branch at Galveston in a Birth Center by certified nurse midwives from the clinics, 2 high-level ultrasound "hub" centers in the outlying region that offer level II ultrasound and maternal-fetal medicine specialist consultation on site, and linkage of all sites to our electronic medical record, telemedicine, and telegenetics consultation. We also developed an off-site domiciliary facility at the University of Texas Medical Branch at Galveston. From 1989 to 2004, our clinics grew from 12 to 38 (now serving 123 Texas counties). Annual patient visits increased from approximately 34,000 to 342,926. Deliveries at the University of Texas Medical Branch at Galveston grew from 3,959 in 1990 to an estimated 6,400 in 2004. Underscoring this increase was the probable loss of at least 1,500 deliveries to local hospitals that had previously denied or discouraged admission to Medicaid-eligible pregnant women. Many women chose to deliver in our hospital even although they had to travel a longer distance to reach our facility. Our experience has shown that patient-centered care can be a viable business strategy to maintain and expand patient volumes and will work even where there are serious geographic disadvantages.