Partnering For Progress: State Policy Strategies To Eliminate Cervical Cancer
2006 was a banner year for cervical cancer prevention – awareness of the disease and its cause, the human papilloma virus (HPV), reached an all time high and significant technological innovations are available for prevention, including HPV testing and HPV vaccines. Many advocacy groups and media outlets named HPV vaccines as the top health innovation of last year (CBS News Healthwatch, Dec. 20, 2006). However, this disease continues to kill thousands of women in the United States and remains the second most common cancer among women worldwide. We have the tools to prevent cervical cancer, but now we must ensure that all women and girls have access to these technologies, regardless of race/ethnicity, socioeconomic status, or other factors.
In response to access issues in the U.S., Women In Government (WIG), a nonprofit, bipartisan organization working with female state legislators, recently issued the third edition of a study that documents progress, gaps, and opportunities in public policy related to cervical cancer. The 2007 State of Cervical Cancer Prevention in America report grew out of the Challenge to Eliminate Cervical Cancer campaign, which advocates for state legislative efforts to make advanced and appropriate technologies available, especially to diverse populations. WIG strongly promotes collaboration among stakeholders working on the issue.
The report analyzes a variety of factors by state, including: incidence, mortality, Pap screening rates, screening of the uninsured, Medicaid coverage of HPV testing, rates of uninsured women, legislation mandating coverage of cervical cancer screening, cervical cancer task forces and commissions, and miscellaneous legislation, such as awareness programs. Each factor was scored on a scale of zero to two points, for a total of 18 possible points. States received grades of fair, good, very good or excellent. Many states scored in the category of good or above, with one state, Minnesota, receiving the first-ever score of excellent. The results of this study are positive, but there is still room for significant improvements, such as expanded use of new HPV vaccines and strategies to reach groups of women who are seldom or never screened.
Key findings of this year’s report indicate that there are robust rates for Pap screening, widespread coverage for advanced technologies, including HPV testing, and significant legislation aimed at eliminating cervical cancer. Perhaps the most important finding is that there is a continued decline in incidence and mortality on a state level. While the momentum for cervical cancer prevention is extraordinary, disparities continue to exist at a national level in terms of incidence, mortality, and screening.
WIG has proposed a series of recommended actions for policymakers to address cervical cancer disparities. First, states should build coalitions among stakeholders to implement elimination strategies, including vaccines and screening for vulnerable populations. In regard to FDA-approved HPV vaccines, WIG advocates school-entry requirements, widespread health coverage, and other measures to support the infrastructure needed for vaccine access. Next, states should ensure reimbursement and public funding for Pap smears and HPV testing. Furthermore, data quality and collection need ongoing support and improvement to evaluate programs and services. Finally, states should continue to develop and fund cervical cancer and HPV public education and awareness programs.
Since the launch of the campaign in 2004, 45 states have introduced legislation. These results required the efforts of stakeholders throughout the public health, private, and policy sectors. In the future, WIG will continue to collaborate with legislators, agencies, advocates, physicians, and other partners to ensure continued progress. 2006 was a year of innovation and awareness – 2007 should focus on access, especially for underserved women and girls.
For more information about Women In Government, the 2007 State of Cervical Cancer Prevention in America report and the Challenge to Eliminate Cervical Cancer campaign, please visit: http://www.womeningovernment.org.
The Relationship Between Pre-Pregnancy Body Mass Index And Folic Acid Birth Defects
In the United States, over the past three decades, there has been a consistent trend toward women delaying childbearing until their late 30s and 40s, due to a combination of social, educational and economic factors. Understanding how chronic conditions, such as obesity, affect childbearing outcomes is increasing in importance as the prevalence of overweight and obesity among pregnant women continues to rise.
According to the Florida Pregnancy Risk Assessment Monitoring System (PRAMS) 2000 to 2001 survey data, 33.1 percent of new mothers in Florida were either overweight or obese prior to pregnancy. Compared to women with normal weight, these women had a significantly increased risk of having an infant with a neural tube defect (NTD), especially spina bifida, likely caused by folic acid deficiencies during pregnancy. Cleft lip with or without cleft palate (CLP) is another malformation caused by a deficiency in folic acid. It has been suggested that high BMI changes the folate availability, and 400 mg a day might not provide the same level of protection against NTD and CLP in overweight and obese women as compared normal weight women. Therefore, women who are overweight and obese may require a higher dose of folic acid than women of normal weight. The objective of this study was to examine the relationship between pre-pregnancy weight and folic acid-related birth defects among women of advanced maternal age in Florida.
This study concluded that overweight/obese women 35 years of age and over were not at higher risk of folic acid related birth defects compared to normal weight women in the same age group, after controlling for potential confounding factors. There were only 12 cases of folic acid-related birth defects in five years (1999-2000) in women of advanced maternal age. This is less than the nationally reported rate of 1 case per 1,000. The small number of birth defect cases within this study sample may be the reason why no relationship was found between obesity and folic acid related birth defects in older women. A possible explanation for the difference in findings is that women of advanced maternal age may be getting enough folic acid regardless of their BMI.
Given the limitations of this study, further research needs to be done. Case studies could be conducted on women who have infants with folic acid related birth defects. Examining each case individually would provide researchers insight about increased risk of delivering an infant with a birth defect. Important aspects to consider are: medical history, knowledge of folic acid, physician recommendation to take a folic acid supplement, diet prior to and during pregnancy, folic acid intake prior to and during pregnancy, working and living conditions, education level, and alcohol and drug use during pregnancy. For a full version of the study, including tables, figures, and references, contact the author, Julia Ackerman, at ackermanj@peds.ufl.edu.
Folic Acid Counseling Tutorial Available Online
Do you think you know everything about folic acid counseling? You owe it to women to be sure! Take the ABCs of Folic Acid Counseling, a new CE tutorial from the Spina Bifida Association, www.sbaa.org, developed with cooperation from the Centers for Disease Control and Prevention.
Continuing education credits are being offered for nurses and health educators, based on one hour of instruction, free of charge. A 10 question pretest will help you to find out how much you know. After taking this CE tutorial, you will be able to:
1. Discuss the general importance of folic acid.
2. Discuss the folic acid recommendation.
3. Use the steps in folic acid counseling.
4. Use one minute of folic acid counseling during an interaction with a woman.
5. Identify women at risk for recurrence of spina bifida or another neural tube defect.
6. Prepare evaluation plans for folic acid counseling.
Taking folic acid prior to pregnancy can reduce the risk of neural tube defects like spina bifida by up to 70 percent. You owe it to women and to yourself to know everything about folic acid! CEU, CNE, and CHES credits are available. To take the course, go to http://sba-resource.org/sbaacd/.
Related Headlines
· Food Fortification not Enough to Prop Up Female Folate Levels: Despite fortification of the food supply with folic acid, serum folate levels have fallen en masse among women in recent years, researchers in Atlanta said. http://www.medpagetoday.com/PrimaryCare/DietNutrition/tb2/4813.
· Spina Bifida Risk Linked to Choline Metabolism Gene Variants: A genetic analysis of spina bifida children in College Station, Texas has revealed the influence of variant cholinemetabolism genes in the development of the disease in addition to perinatal consumption of cholinerich foods. http://www.medpagetoday.com/OBGYN/Pregnancy/tb2/4749
· Cerebral Palsy Rates Decline in Very Low Birthweight Children: Researchers in Liverpool, England reported that premature babies have a better chance of survival without severe neurological impairment than they did in the 1980s. http://www.medpagetoday.com/Neurology/GeneralNeurology/tb2/4812
See more MCH Headlines from MedPage Today at the end of the newsletter.
National Survey Findings Available Online
The Child and Adolescent Health Measurement Initiative (CAHMI) presents the Data Resource Center for Child and Adolescent Health. This resource is a no-cost, easy-to-use Web site that puts national, state, and regional survey findings right at your fingertips! As part of the Data Resource Center, you will find:
· interactive data search tools.
· personalized technical help by e-mail or telephone.
· information and examples to help you use data more effectively.
National Survey of Children’s Health: At www.nschdata.org, you can search and compare findings on:
· child health measures: over 60 measures of health and well-being of children, youth, and families.
· state profiles: check out your state profile, and compare results from the state profile pages for children of different ages, race, income, and health status.
· Healthy People 2010: query the survey content and child health indicators related to Healthy People 2010.
· survey sections: query and compare results for questions asked in each section of the survey.
National Survey of Children with Special Health Care Needs: At www.cshcndata.org, you can search and compare findings on:
· prevalence and demographics: child or household level data about children with and without special health care needs.
· health and system performance measures: compare MCHB outcomes and key indicators for children and youth with special health care needs (CYSHCN) of various ages, race, income, and health groups.
· state profiles: check out your state profile, and further explore state profile indicators by comparing results for different groups of CYSHCN.
· survey sections: compare results from questions asked in each section of the CYSHCN interview part of the survey.
The Data Resource Center for Child and Adolescent Health is a project of the Child and Adolescent Health Measurement Initiative (CAHMI). Visit us at www.childhealthdata.org.
What have you learned about child and adolescent health today?
Children’s Health Initiatives: First Step To Universal Health Coverage In California
Nineteen counties in California have developed the Children’s Health Initiatives (CHI), to provide universal health coverage to children. These initiatives build on coverage available through Medi-Cal and Healthy Families (California’s Medicaid and S-CHIP programs), by serving low-income kids who do not meet the immigration status or income criteria of these two programs. The Urban Institute, Mathematica Policy Research, Inc., and local partners are conducting evaluations of the CHI programs in three counties: Santa Clara, San Mateo, and Los Angeles. All three initiatives include an insurance product (“Healthy Kids”) targeting uninsured children, and an outreach campaign to find uninsured children and enroll them. These programs primarily serve low-income, non-citizen, Latino children, and offer comprehensive coverage of primary, specialty, and hospital services, including dental and vision coverage. This article describes some of the most interesting findings about outreach, enrollment, utilization, and financing are emerging from the evaluation of these initiatives
The Santa Clara Healthy Kids program has enrolled more than 30,000 children since 2001, and the evaluation has found that, prior to enrolling Healthy Kids, enrollees had spent most of their lives uninsured. Almost half had never had health insurance coverage of any kind, while 13 percent had only emergency coverage through Medi-Cal (http://www.mathematica-mpr.com/publications/PDFs/santaclara.pdf). The evaluation also shows that new health insurance coverage led to significant improvement in children’s access to care, use of services, and health according to several measures. More results are available in a 2006 free on-line article in Health Services Research at: http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1475-6773.2006.00625.x
The San Mateo evaluation has found increasing use of preventive and ambulatory medical care, dental care, and vision care from the first to the second year of enrollment in Healthy Kids. The evaluation suggests that increased enrollment among higher income families in 2005 is likely due to a school-based approach, which may reduce the stigma of applying for a public program. These and other findings from the San Mateo evaluation report are available at http://www.urban.org/url.cfm?ID=411365.
The Los Angeles Healthy Kids program currently enrolls over 40,000 children. Evaluation reports are available on the First Five LA Web site at http://www.first5la.org/ourprojects/healthykids.php4. Evaluation findings in LA have been overwhelmingly positive, showing that access to care is particularly good for preventive and primary care services (UI brief at http://www.urban.org/url.cfm?ID=411370). In focus groups, parents reported that the application process is easy, trusted community-based outreach workers are very helpful and succeed in dispelling fears related to applying for coverage, and the benefit package is meeting children’s needs (UI brief at http://www.urban.org/url.cfm?ID=410308).
An ongoing issue for all of the CHI programs has been sustainability, since all initiatives have been funded in part by philanthropic donations. In an article discussing policy issues in implementing the Santa Clara and San Mateo initiatives, Embry Howell and Dana Hughes wrote that “success depends on leadership from county agencies that have not traditionally worked closely together, as well as the development of a diverse public and private funding base. This effort to provide universal coverage for all children is important to national policymakers desiring similar goals.” (Milbank Quarterly, Vol. 84, No. 3. Fall, 2006.)
Currently, California policymakers are debating legislative options to attain universal coverage, spurred on by the Governor’s proposal, which includes expansion of public programs, an individual mandate to buy private coverage for those not reached by public subsidies, and guaranteed issue when shopping for coverage in the private market. New legislation also will have to address how children covered by the Healthy Kids programs will be wrapped into a new or existing state and federal programs, and whether undocumented children and their parents will be included in the new coverage landscape.
Future Search Featured At MCH Federal/State Partnership Meeting
In the timeless quest for such a “better possibility”, the 2006 MCH Federal/State Partnership Meeting, held in Washington, D.C., on Oct. 15-18, focused on the theme of Leadership, Vision, and a Legacy for the Future of Maternal and Child Health. The MCH Bureau Planning Committee decided to incorporate Future Search, a uniquely innovative and interactive planning and leadership tool, into the 2006 Partnership Meeting as an exciting approach for creating such vision. As an MCH medical director in three states over the past 30 years and a practitioner of Future Search since 1993, I had the honor of helping to design and lead the seven Future Search sessions for the MCH Partnership Meeting.
Future Search is a 2-1/2 day planning process, embodying a philosophy of leadership which recognizes that every person does the best they can with what they have, and that all come equipped with the capacity for extraordinary cooperation if given a chance to use their own experience and wisdom. Future Search is based on four common sense principles:
· In order to create plans that are both visionary and practical, “the whole system,” i.e., all those with authority, resources, experience, information, and need, must be in the room.
· In order to create action plans based on genuine dialogue and commitment, participants must be given a chance to explore the whole before seeking to fix any part.
· Common ground and desirable futures must be a priority, and problems and conflicts must be treated as information, not action items.
· Individuals must manage their own work and take responsibility for acting on what they learn.
Future Search has proven especially useful in stressful situations in which deeply entrenched systems and policies are under pressure to change. Because Future Search has people work with their own knowledge and experience, using structured dialogues as a key procedure, it is used all over the world to create umbrellas for social, economic, and educational change that endures, including:
· Vermont, 2000: used to develop a recently enacted universal health coverage plan for the state.
· New Mexico, 1997: used to develop several successful grant proposals to support parenting education and child care.
· Seattle, 2000: used to help the mayor develop a $7 million budget for human services.
· Nevada, 1997: used to establish the Nevada Public Health Foundation.
· Montana: used to increase youth participation in the governance of 4-H clubs.
· Minneapolis: used to reduce school absenteeism from asthma.
· Nebraska: used to enable a grassroots organization, Community Connections, to obtain a $1.2 million grant to expand before-school, after-school, and summer programs, and to reduce tobacco use.
The video and text of the MCH Partnership Meeting are now available on the MCH Bureau Web Site at www.cademedia.com/archives/mchb/partnership2006/ , and a DVD will soon be available. For more information about Future Search, contact Richard Aronson, MD, MPH, Maine MCH medical director, for further information, at Richard.Aronson@maine.gov, or (207)287-5345, or go to www.futuresearch.net.
To What Extent Does The Ongoing Political Crisis Imperil The Life Of Mothers And Newborns In Cote D’Ivoire?
Background: Cote d’Ivoire is a developing country of sub-Saharan Africa where an armed conflict occurred, starting Sep. 19, 2002, generating displaced and refugee populations. The war was followed by a long-term political crisis, which resulted in the partition of the country and a disruption of development efforts and health services. This study aims to measure the extent to which the ongoing political crisis imperils the life of mothers and newborns in Côte d’Ivoire.
Methods: We carried out a retrospective cohort study from April 2005 to September 2005. The whole population of the country and their health environment was considered as exposed and thus included in this study. To verify that differential exposure to military crisis occurred between the control and cohort groups, to identify significant differences between the groups, and to determine whether cohort and control groups had significantly different health risks, statistical tests, including chi-square of Mantel Haenzel and p-value, were performed.
Results: The public health consequences of the mass population displacement have resulted in an extremely high rate of unattended births. A nationwide curfew in 2002 and 2003 accounted for at least 5 percent of childbirths at home. In the besieged zone, from 25 percent to 45 percent of pregnancies resulted in stillbirths (p<0.001). Records of newborn births with a low birthweight taken at that time showed an important difference between control and cohort groups (p<0.001) and the attributable risk increased significantly from 22 to 32 percent (2002 through 2003). All these poor pregnancy outcomes can be attributed to the political crisis and might have been avoided if the crisis had not occurred.
Conclusion: This study assessed the effects of the political crisis on maternal and newborn health in Côte d’Ivoire. It emerges from this study that the political crisis adversely affected pregnancy outcomes and newborn health. These study results have potential to raise awareness and to stimulate change for peace.
---------------------------------------------------------------------------------------------------------------------------------Acknowledgement: Funding to support this research was made available by the Center for Epidemiology, Population and Development (CEPOD) www.thecepod.org. Correspondence to Dr Raymond G. DOGORE, MD, MPH, 25 BP 1009 Abidjan 25 –Côte d’Ivoire.
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Brief Adolescent Health-Risk Assessment
1. Have you ever been held back in school for attempting to take your own life by smoking at least half a pack of cigarettes a day while going twenty miles or more over the speed limit during penetrative sex on your skateboard without using a seatbelt, helmet, condom, or dental floss after injecting five or more high fat drinks in a row with a contaminated handgun?
_____YES _____NO
The Editor would gladly credit the original author of this classic if she knew who it was.
MCH Headlines
· The Year in Pediatrics: Childhood obesity remained a focus of pediatrics during the year, along with concerns about safety, particularly the safety of psychiatric medications. http://www.medpagetoday.com/Pediatrics/GeneralPediatrics/tb2/4782
· Childhood Vaccination Schedule Expanded for 2007: In Atlanta, a more comprehensive vaccination schedule for children and adolescents has been issued by the CDC for 2007. http://www.medpagetoday.com/InfectiousDisease/Vaccines/tb2/4792
· Hypertension During Pregnancy Linked to Later Heart Disease: Researchers in Utrecht, the Netherlands, reported that, even if hypertension during pregnancy subsides after delivery, a risky postmenopausal second act may await. http://www.medpagetoday.com/OBGYN/Pregnancy/tb2/5004
· Uterus Proposed as Transplant Candidate: The next step in assisted reproduction may be a uterus transplant, according to researchers in New York. http://www.medpagetoday.com/Endocrinology/Infertility/tb2/4783
· New Mothers Benefit from a Course on Sleep: For sleep-deprived new mothers, some planning and training may translate into nearly an extra hour of welcome shut eye, according to a small Toronto study. http://www.medpagetoday.com/OBGYN/Pregnancy/tb2/4631
· Abortion Compound Shrinks Fibroids: Low doses of Mifeprex (mifepristone), the compound at the heart of the abortion pill, shrink uterine fibroids and improve quality of life for women with the condition, according to researchers in Rochester, N.Y. http://www.medpagetoday.com/OBGYN/Fibroids/tb2/4653
· Car Safety Seats May Cause Breathing Problems for Infants: When infants take lengthy naps in child safety seats, the babies may risk life-threatening oxygen desaturation, according to a small study in Auckland, New Zealand. http://www.medpagetoday.com/Pediatrics/GeneralPediatrics/tb2/4667
· Sleep Upset Paired With Depression in Kids: Poor sleep is a frequent companion of depression in children, according to researchers in Pittsburgh. http://www.medpagetoday.com/Pulmonary/SleepDisorders/tb2/4785
· Kids Bring Out Fat-Filled Diets for Elders: Children may be a bad influence on the diets of the adults around them, researchers reported in Iowa City. http://www.medpagetoday.com/PrimaryCare/DietNutrition/tb2/4780
· Surgery Usually Succeeds in Pediatric Renovascular Hypertension: Researchers in Ann Arbor reported that surgery for renovascular hypertension in children is nearly always successful in curing or improving the high blood pressure. http://www.medpagetoday.com/Cardiology/Hypertension/tb2/4779
· Higher IQ Children Grow into Vegetarians: Smarter kids are more likely to adopt limited vegetarianism when they mature, according to a large British cohort study published in Southampton. http://www.medpagetoday.com/PrimaryCare/DietNutrition/tb2/4721
· FDA Approves Head-Cooling Device to Treat Newborn Brain Disorder: In Rockville, Md.; the FDA approved Olympic CoolCap, a device that cools the head to prevent damage caused by neonatal hypoxicischemic encephalopathy (HIE), a condition that affects 5,000 to 9,000 newborns each year. http://www.medpagetoday.com/ProductAlert/DevicesandVaccines/tb2/4748
· ACOG Says All Pregnancies Should Be Evaluated for Down’s: The maternal age of 35 should no longer be the primary benchmark for testing pregnancies for Down's syndrome, according to new recommendations from the American College of Obstetricians and Gynecologists (ACOG) in Washington, D.C. http://www.medpagetoday.com/OBGYN/Pregnancy/tb2/4784
· Autism Spectrum Disorders Far More Prevalent Than Thought: Autism spectrum disorders are much more common than previously thought, and could affect as many as one in 150 school-age children, CDC researchers in Atlanta reported. The prevalence was highest in New Jersey among 14 states surveyed. http://www.medpagetoday.com/Pediatrics/Autism/tb2/5027
· Smaller Brain Structures in Autism Linked to Social Deficits: Severe social deficits in males with autism has been traced by investigators in Madison, Wisc. to shrinkage of the amygdala, the component of the limbic system that governs nonverbal responses to threats. http://www.medpagetoday.com/Pediatrics/Autism/tb2/4637
· Prenatal Pesticide Exposure Delays Mental Development: Inner-city children exposed in utero to high levels of a now-banned pesticide had significantly greater delays in mental and psychomotor development than peers with low prenatal exposure, investigators reported from New York. http://www.medpagetoday.com/PublicHealthPolicy/EnvironmentalHealth/tb2/4655
· Parents of Disabled Child Defend Growth-Retarding Therapy: In Seattle, parents of a severely cognitively and physically disabled girl have publicly defended their decision to retard her growth through the use of hormonal therapy and surgery, saying they were acting out of love and compassion. http://www.medpagetoday.com/Pediatrics/Parenting/tb2/4814
· Binge Drinking Common Among High Schoolers: Binge drinking is common among high school students and is tied to other risky behaviors, according to a national survey by the CDC in Atlanta. http://www.medpagetoday.com/Pediatrics/GeneralPediatrics/tb2/4790
· Youthful Drinking Jumpstarts Later Alcohol Abuse: When the Marine Corps evaluated thousands of recruits in San Diego, it found that young men, ages 18 to 20, were significantly more likely to become risky drinkers if they started drinking as children or young teenagers. http://www.medpagetoday.com/Psychiatry/Addictions/tb2/4633
· For Meaning of Mammography, Radiologists Reign Over Computer: According to researchers in Seattle, when it comes to mammogram interpretation, the eyes and judgment of radiologists still have it over computer chips. http://www.medpagetoday.com/HematologyOncology/BreastCancer/tb2/4639
· New Questions on Mammography Screening for Young Women: In Leeds, England, the question has once again arisen as to whether women ages 40 to 49 should have routine screening mammograms. http://www.medpagetoday.com/HematologyOncology/BreastCancer/tb2/4665
· FDA Okays Gene Test to Predict Breast Cancer Recurrence: In Rockville, MD, the FDA said it has approved the first microarray genetic analysis designed to aid in predicting the risk of Stage I or II breast cancer recurrence or metastasis. http://www.medpagetoday.com/HematologyOncology/BreastCancer/tb2/5002
MCH Headlines are from MedPage Today(TM), which provides real-time coverage of breaking medical news and the top stories in health and medicine. Physicians may also receive Category 1 CME credit as part of their news coverage. There is no cost to use the service and you can sign up for Daily Headlines e-mail at www.medpagetoday.com/.