Latino Immigrants: Disparities in Reported Prenatal Care Advice From Health Care Providers Among Women of Mexican Origin in California

Poorer birth outcomes have been documented among U.S.-born women of Mexican descent when compared with Mexican immigrant women. Behavioral changes that are associated with acculturation may contribute to these deteriorating outcomes. Prenatal health promotion advice can alter prenatal risk behaviors. The growing diversity of the U.S. population during the 1990s heightens the importance of examining the cultural relevance of current health promotion practices. This study examines disparities in the reported receipt of health behavior advice during pregnancy among U.S.-born women of Mexican origin and Mexican immigrant women in California. Data for the analysis are from the 1994–95 California Pregnancy Risk Assessment Monitoring System. The study sample includes 1,423 women of Mexican descent. All participants had a live birth in California between January 1994 and December 1995. Women were interviewed about the prenatal counseling they received related to diet, smoking, and alcohol use. Logistic regression was used to analyze the likelihood of reporting advice after controlling for sociodemographic and health system characteristics. Immigrant women were more likely than the U.S.-born to report receipt of prenatal advice on smoking, alcohol, and diet (OR = 1.83, p < .05) despite evidence of the lower prevalence of related health risks among Mexican-born women. Culturally appropriate prenatal counseling would emphasize the maintenance of traditional protective behaviors among less acculturated foreign-born women, and the prevention or cessation of those risk behaviors among the more acculturated women.     

Cluster Randomized Controlled Trial of Group Prenatal Care: Perinatal Outcomes Among Adolescents in New York City Health Centers

Objectives. We compared an evidence-based model of group prenatal care to traditional individual prenatal care on birth, neonatal, and reproductive health outcomes.Methods. We performed a multisite cluster randomized controlled trial in 14 health centers in New York City (2008–2012). We analyzed 1148 pregnant women aged 14 to 21 years, at less than 24 weeks of gestation, and not at high obstetrical risk. We assessed outcomes via medical records and surveys.Results. In intention-to-treat analyses, women at intervention sites were significantly less likely to have infants small for gestational age (< 10th percentile; 11.0% vs 15.8%; odds ratio = 0.66; 95% confidence interval = 0.44, 0.99). In as-treated analyses, women with more group visits had better outcomes, including small for gestational age, gestational age, birth weight, days in neonatal intensive care unit, rapid repeat pregnancy, condom use, and unprotected sex (P = .030 to < .001). There were no associated risks.Conclusions. CenteringPregnancy Plus group prenatal care resulted in more favorable birth, neonatal, and reproductive outcomes. Successful translation of clinical innovations to enhance care, improve outcomes, and reduce cost requires strategies that facilitate patient adherence and support organizational change.Bundling health care services—integrating prevention and treatment—is a strategy to meet “triple aim” goals: enhanced health care quality, improved health outcomes, and lower cost.1,2 The institutional benefits of bundling health care include reduced infrastructure and cost, the opportunity to provide additional services, and collaborative partnerships. Patient benefits include integrated services and reduced barriers to care.Pregnancy is an important window of opportunity, with frequent health care contact. Nonetheless, adverse birth outcomes remain leading causes of US infant morbidity and mortality3 and are concentrated among disadvantaged groups.4 Pregnant adolescents also have higher rates of sexually transmitted infection (STI) than do their nonpregnant counterparts and those who are nulliparous.5 Taken together, adolescent women from socially disadvantaged groups face adverse reproductive and sexual health disparities.Yet, bundled preventive interventions are not as common as are those that address individual risk factors.6 Regarding pregnancy, interventions among pregnant adolescents target either reproductive or sexual health, both with limited effectiveness. Clinical interventions such as progesterone administration and cervical cerclage prevent preterm birth in singleton gestations with previous preterm birth or short cervix.7 However, one half of women who deliver preterm have no known risks.8 An independent review of prenatal care models found only 1 randomized controlled trial (RCT) that demonstrated improved health outcomes.9 This study, from our research team, compared CenteringPregnancy group prenatal care to standard individual prenatal care. Our previous research documented that women randomized to group prenatal care had a 33% lower rate of preterm delivery.10 We also documented improved outcomes among women randomized to group prenatal care that bundled reproductive health promotion (CenteringPregnancy Plus): greater than 50% reduction in rapid repeat pregnancy among all women and incident STI among adolescents.11Translating evidence to routine health care practice is a National Institutes of Health priority.12 It is important to determine whether clinical interventions with demonstrated efficacy can be implemented to produce clinical benefits comparable to those observed during efficacy studies. First developed in 1968 to improve well-child care, group care consists of the same components of individual care visits coupled with education and skills building and takes place in a group of patients.13 Previous research across a range of health conditions suggests many clinical and psychosocial benefits, including improved patient self-management, adherence, satisfaction, and clinical outcomes.14 More time between patients and health care providers results in more patient-centered care.We conducted a multisite cluster RCT to assess the clinical effectiveness of group prenatal care bundled with reproductive health promotion compared with the clinical effectiveness of standard individual prenatal care. Cluster randomized trials can evaluate changes in service provision under conditions of actual use and are characterized by their multilevel nature15: in this case, pregnant women clustered into prenatal care settings. We hypothesized that women at clinical sites randomly assigned to deliver group prenatal care would have better reproductive and sexual health outcomes than those of women at sites randomized to individual care and that greater exposure to group prenatal care would be associated with better outcomes. Specifically, a priori outcomes included gestational age at delivery, infant birth weight, and small for gestational age as well as incident STI, rapid repeat pregnancy, and behavioral risk factors (e.g., condom use). We also included admission to and days in the neonatal intensive care unit (NICU).     

Health Status and Health Care Utilization Among New York City Home Attendants: An Illustration of the Needs of Working Poor,Immigrant Women

In this paper, the health needs and health care utilization patterns of home attendants and their families have been studied as an illustration of those likely to be found among working poor, immigrant women and their children. Despite tremendous growth in the number of immigrants, studies to date provide only limited information regarding the specific health needs and patterns of health care utilization among such women and their children. As part of a longitudinal study on the impact of insurance on health status and health care utilization, 387 female, immigrant home attendants were interviewed. Data were also gathered on 355 of their minor children. These women and children were found to be less likely than other Americans to make use of basic health services, despite the fact that they are more likely to indicate fair or poor health status. This is true even in comparison to poor or uninsured Americans. Immigrant attendants in fair or poor health report an average annual visit rate of 4.1 ambulatory care visits for themselves and 2.2 for their children, as compared to 8.4 for poor adults and 4.4 for poor children in national samples. These findings illustrate the likelihood that poor, immigrant women make limited use of American medical care, and face barriers to health care that appear even greater than those faced by the uninsured and the poor.     

Welfare Reform and Health of Immigrant Women and their Children

We investigate the association between the 1996 welfare reform and health insurance, medical care use and health of low-educated, foreign-born, single mothers and their children. We find that welfare reform was associated with an eight to 11.5 percentage points increase in proportion uninsured among low-educated foreign-born, single mothers. We also find that the decline in welfare caseload since 1996 was associated with a 6.5 to 10 percentage points increase in the proportion of low-educated foreign-born, single mothers reporting delays in receiving medical care or receiving no care due to cost and a nine percentage points decline in visits to a health professional in the past 12 months. We do not find any consistent evidence that welfare reform affected the health insurance, medical care utilization and health of children living with single mothers.     

Residential Segregation and Latino, Black and White Mortality in New York City

Although racial segregation is associated with health status, few studies have examined this relationship among Latinos. We examined the effect of race/ethnic group concentration of Latinos, blacks and whites on all-cause mortality rates within a highly segregated metropolitan area, New York City (NYC). We linked NYC mortality records from 1999 and 2000 with the 2000 U.S. Census data by zip code area. Age-adjusted mortality rates by race/ethnic concentration were calculated. Linear regression was used to determine the association between population characteristics and mortality. Blacks living in predominantly black areas had lower all-cause mortality rates than blacks living in other areas regardless of gender (1616/100,000 vs. 2014/100,000 for men; 1032/100,000 vs. 1362/100,000 for women). Amongst whites, those living in predominantly white areas had the lowest mortality rates. Latinos living in predominantly Latino areas had lower mortality rates than those in predominantly black areas (1187/100,000 vs.1950/100,000 for men; 760/100,000 vs. 779/100,000 for women). After adjustment for socioeconomic conditions, whites, older blacks, and young Latino men experienced decreasing mortality rates when living in areas with increasing similar race/ethnic concentrations. Increasing residential concentration of blacks is independently associated with lower mortality in older blacks; similarly, increasing residential concentration of Latinos and whites is associated with lower mortality in young Latino men and whites, respectively.Inagami and Asch are with the Veterans Affairs, VA Greater Los Angeles Health Care System, Division of General Internal Medicine (111G), 11301 Wilshire Blvd, Los Angeles, CA 90073, USA; Borrell is with the Columbia University, Mailman School of Public Health, 600 West 168th Street, PH 18-331, New York, NY 10032, USA; Wong, Shapiro, and Asch are with the Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, 911 Broxton Plaza, Los Angeles, CA 90095-1736, USA; Fang is with the Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, Center for Disease Control and Prevention, 4770 Buford Hwy. NE, MS K-47, Atlanta, GA 30341-3717, USA; Asch is with the RAND Health, Division of General Internal Medicine (111G), 11301 Wilshire Blvd, Los Angeles, CA 90073, USA.     

2004年广州市部分女职工保健工作开展及服务利用情况调查

[目的]了解广州市企事业单位女职工保健工作开展及服务利用情况,探索新世纪女职工保健工作的模式与方法。[方法]2004年底,对广州市154家企事业单位进行了女职工保健工作开展及服务利用情况的调查。[结果]调查152家单位,不同性质的单位在女工保健措施配备、部分保健服务利用方面存在差异;30.3%的单位由女工负责人落实妇女病普查工作,47.4%的单位配备了防护措施;妇科检查、盆腔B超、乳腺近红外线扫描、查宫内节育环的利用率分别为94.7%、69.1%、76.3%、48.0%。[结论]不同性质单位女职工劳动保护工作发展不平衡,有的国有企业和机关事业单位采取的保健措施甚至不及外商投资和股份制企业。政府应加强和重视女工劳动保护设施的监督,加大保健服务利用的力度,保障女工的合法权益和身心健康。     

The Representation of Health Professionals on Governing Boards of Health Care Organizations in New York City

The Representation of Health Professionals on Governing Boards of Health Care Organizations in New York City. The heightened importance of processes and outcomes of care—including their impact on health care organizations’ (HCOs) financial health—translate into greater accountability for clinical performance on the part of HCO leaders, including their boards, during an era of health care reform. Quality and safety of care are now fiduciary responsibilities of HCO board members. The participation of health professionals on HCO governing bodies may be an asset to HCO governing boards because of their deep knowledge of clinical problems, best practices, quality indicators, and other issues related to the safety and quality of care. And yet, the sparse data that exist indicate that physicians comprise more than 20 % of the governing board members of hospitals while less than 5 % are nurses and no data exist on other health professionals. The purpose of this two-phased study is to examine health professionals’ representations on HCOs—specifically hospitals, home care agencies, nursing homes, and federally qualified health centers—in New York City. Through a survey of these organizations, phase 1 of the study found that 93 % of hospitals had physicians on their governing boards, compared with 26 % with nurses, 7 % with dentists, and 4 % with social workers or psychologists. The overrepresentation of physicians declined with the other HCOs. Only 38 % of home care agencies had physicians on their governing boards, 29 % had nurses, and 24 % had social workers. Phase 2 focused on the barriers to the appointment of health professionals to governing boards of HCOs and the strategies to address these barriers. Sixteen health care leaders in the region were interviewed in this qualitative study. Barriers included invisibility of health professionals other than physicians; concerns about “special interests”; lack of financial resources for donations to the organization; and lack of knowledge and skills with regard to board governance, especially financial matters. Strategies included developing an infrastructure for preparing and getting appointed various health professionals, mentoring, and developing a personal plan of action for appointments.     

Factors Associated with Sexual and Reproductive Health Care by Mexican Immigrant Women in New York City: A Mixed Method Study

Limited research has examined barriers to sexual and reproductive health (SRH) services for Mexican immigrant women, especially those living in the eastern United States. This mixed-method study describes SRH care utilization and barriers experienced by female Mexican immigrants living in New York City. One hundred and fifty-one women completed surveys, and twenty-three also participated in focus groups. Usage of SRH care was low apart from prenatal services. The highest barriers included cost, language differences, child care, and poor service quality. After adjusting for insurance status, barriers were associated with receipt of gynecological care from a clinic or private doctor. Greater SRH knowledge was associated with current contraceptive use and a recent PAP test. Women reported that promotoras could increase information about SRH and decrease barriers. Results suggest that in a context where services are geographically available, health care utilization is impacted by lack of knowledge and structural barriers such as language, cost, and child care. Implications for community outreach are discussed.     

Initiation of and Barriers to Prenatal Care Use Among Low-Income Women in San Antonio,Texas

Healthy People 2010 goals set a target of 90% of mothers starting prenatal care in the first trimester of pregnancy. While there are questions about the value of prenatal care (PNC), there is much observational evidence of the benefits of PNC including reduction in maternal, fetal, perinatal, and infant deaths. The objective of this study was to understand barriers to PNC as well as factors that impact early initiation of care among low-income women in San Antonio, Texas. A survey study was conducted among low-income women seeking care at selected public health clinics in San Antonio. Interviews were conducted with 444 women. Study results show that women with social barriers, those who were less educated, who were living alone (i.e. without an adult partner or spouse), or who had not planned their pregnancies were more likely to initiate PNC late in their pregnancies. It was also observed that women who enrolled in the WIC program were more likely to initiate PNC early in their pregnancies. Women who initiated PNC late in pregnancy had the highest odds of reporting service-related barriers to receiving care. However, financial and personal barriers created no significant obstacles to women initiating PNC. The majority of women in this study reported that they were aware of the importance of PNC, knew where to go for care during pregnancy, and were able to pay for care through financial assistance, yet some did not initiate early prenatal care. This clearly establishes that the decision making process regarding PNC is complex. It is important that programs consider the complexity of the decision-making process and the priorities women set during pregnancy in planning interventions, particularly those that target low-income women. This could increase the likelihood that these women will seek PNC early in their pregnancies.     

Latino Population Growth and Hospital Uncompensated Care in California

Objectives. We examined the association between the size and growth of Latino populations and hospitals’ uncompensated care in California.Methods. Our sample consisted of general acute care hospitals in California operating during 2000 and 2010 (n = 251). We merged California hospital data with US Census data for each hospital service area. We used spatial analysis, multivariate regression, and fixed-effect models.Results. We found a significant association between the growth of California’s Latino population and hospitals’ uncompensated care in the unadjusted regression. This association was still significant after we controlled for hospital and community population characteristics. After we added market characteristics into the final model, this relationship became nonsignificant.Conclusions. Our findings suggest that systematic support is needed in areas with rapid Latino population growth to control hospitals’ uncompensated care, especially if Latinos are excluded from or do not respond to the insurance options made available through the Affordable Care Act. Improving availability of resources for hospitals and providers in areas with high Latino population growth could help alleviate financial pressures.Uncompensated hospital care for the uninsured and underinsured imposes a significant financial burden on the US health care system. The American Hospital Association reported that uncompensated care rose to $45.9 billion in 2012, which accounted for 6.1% of total hospital expenses that year.1 This problem affects hospitals’ financial stability and ability to recoup losses from reduced payments, which in turn can hurt their ability to care for the local population, operate emergency department and specialty services to meet patient needs, and maintain optimal nurse staffing ratios.2–4Hospitals have typically responded to increased uncompensated care by increasing prices for paying patients5; however, Medicaid and Medicare payments have been reduced, and it has become more difficult to shift costs to private payers. Uncompensated care also affects all levels of government, which provide subsidies to offset these losses through other programs.6 The largest source of federal funding for uncompensated care—Medicaid Disproportionate Share Hospital (DSH) payments—totaled $11.4 billion in 2012.7 Despite these mechanisms that indirectly subsidize hospitals’ provision of uncompensated care, hospital closures have been linked to uncompensated care.8Hospital administrators, policymakers, and advocates for the uninsured hoped that the Patient Protection and Affordable Care Act (ACA) would provide health insurance to many of the almost 50 million previously uninsured Americans and thereby significantly reduce uncompensated care. The Supreme Court’s decision on the ACA allows states to opt out of the mostly federally funded Medicaid expansion, which will likely lower the projected numbers of Americans who obtain coverage and potentially undermine the predicted decreases in future uncompensated care by hospitals.9 Existing policy efforts focus on decreasing hospital payments to reduce health care spending,10 and DSH payments are being reduced in anticipation of increases in insurance coverage in all states.11 These recent health policy developments have brought the problem of uncompensated hospital care into a new focus, generating increasing interest in understanding what factors affect hospitals’ financial stress.Some have suggested that immigrants use large amounts of uncompensated care,12 potentially implicating the Latino population—the nation’s largest immigrant group13—in rising uncompensated care. However, hospital uncompensated care may also decrease because of Latinos’ low health care utilization14–21 and expenditures,22–25 which have been described in the context of the healthy immigrant effect (i.e., Latino immigrants are usually younger and healthier than Latinos born in the United States)26 and other factors (e.g., fewer available health care resources, lack of linguistically appropriate care, discrimination in health care settings, and fear of deportation among undocumented Latinos).27,28 Empirical evidence for the potential impact of changing Latino demographics on hospitals’ uncompensated care is limited at best. A study of Oregon state data found weak evidence of an association between the size of the Latino population and hospital uncompensated care.27 A nonsignificant relationship might have reflected Latinos’ immigrant status, limited health care access, and unwillingness or inability to seek health care.California’s hospitals account for more than 10% of uncompensated care nationally.29 California has the largest Latino population of any state, as well as the largest growth rate in its Latino population.29 In 2012, 44.5% of California''s uninsured population was Latino.30 Among the uninsured Latino population in the state, more than 1 million will remain uninsured, even after the ACA’s coverage expansions.31,32 Although some are able to temporarily access emergency Medicaid services for significant, emergent health issues, the majority are uninsured and require help from local indigent care programs, hospital charity care, federally qualified health centers, or other safety net providers. Hence, California, because of its high number (7 million) and percentage (20%) of uninsured residents prior to the ACA,33 offers an excellent setting to study the impact of the Latino population on the uninsured rate, uncompensated care need, and local safety net providers.We examined the association between Latino population growth rates and hospitals’ uncompensated care in California between 2000 and 2010. These growth rates not only reflected the marginal increases in uncompensated care and Latino population estimates, but also took into account baseline levels of these variables. Because growth rates are considered to be better than the level measures for predicting future population growth trends,34 our findings could have important policy implications regarding the allocation of health care resources.     

Meaningful Use of an Electronic Health Record in the New York City Jail System

Use of electronic health records (EHRs) is an important innovation for patients in jails and prisons. Efforts to incentivize health information technology, including the Medicaid EHR Incentive Program, are generally aimed at community providers; however, recent regulation changes allow participation of jail health providers. In the New York City jail system, the Department of Health and Mental Hygiene oversees care delivery and was able to participate in and earn incentives through the Medicaid EHR Incentive Program. Despite the challenges of this program and other health information innovations, participation by correctional health services can generate financial assistance and useful frameworks to guide these efforts. Policymakers will need to consider the specific challenges of implementing these programs in correctional settings.     

Latina Self-Reported Mental Health and Delay in Health Care in a New Latino Destination

Understanding how depression and/or anxiety affects use of health care among Latinas in rapidly growing new Latino destinations, population where the growth rate of the Latino population exceeds the national average, may enhance community engagement efforts. Using community-based participatory research, a questionnaire assessing health care use was administered to 289 Latinas. Most (70%) reported delaying healthcare, and self-reported depression/anxiety was associated with a 3.1 fold (95% CI: 1.6–5.9) increase in delay, after adjusting for current health status, acculturation, age, education, and place of birth. Mental health disparities exist among Latinas, which are related to delays in use of health care. A gap exists regarding health education interventions for Latinas. More research is needed to identify successful models, especially in new Latino destinations as they may be particularly vulnerable to delay care.     

早期围产保健对孕产妇妊娠结局的影响

目的 探讨早期围产保健对孕产妇妊娠结局的影响.方法 选取2006年4月-2008年5月在赵县的医院住院的2 859例孕产妇.其中以2007年5月-2008年5月赵县建立孕产妇管理系统,实施早期围产保健的1 524例孕产妇作为观察组,以2006年4月-2007年4月未实施早期围产保健的1 335例孕产妇作为对照组.对比两组孕产妇的产前检查情况、分娩方式、分娩期出血量、第三产程时间、分娩时体重超标率以及产褥感染、宫缩乏力、妊娠高血压和妊娠糖尿病等并发症.结果 观察组和对照组产前检查、分娩方式,两组差异均有统计学意义(P<0.05),观察组产前检查3～4次、≥5次的构成比以及正常产的构成比均显著高于对照组(P<0.05).观察组的分娩期出血量、第三产程时间和分娩时体重超标率,均显著低于对照组,两组差异均有统计学意义(P<0.05).观察组的产褥感染、宫缩乏力、妊娠高血压和妊娠糖尿病等并发症发生率,均显著低于对照组,两组差异有统计学意义(P<0.05). 结论 通过早期围产保健,可以加强孕产妇产前检查,减少孕产妇不良妊娠结局的发生率.     

Intimate Partner Violence and Consistent Condom Use Among Drug-Using Heterosexual Women in New York City

The present study examined the associations of relationship factors, partner violence, relationship power, and condom-use related factors with condom use with a main male partner among drug-using women. Over two visits, 244 heterosexual drug-using women completed a cross-sectional survey. Multivariate logistic regression models indicated that women who expected positive outcomes and perceived lower condom-use barriers were more likely to report condom use with their intimate partners. The findings suggest that future interventions aiming at reducing HIV risk among drug-using women should focus on women's subjective appraisals of risks based on key relationship factors in addition to the occurrence of partner violence.     

The Role of the Nutritionist in a New York City Based Long-Term Home Health Care Program

No abstract available for this article.