The July/August 2003 issue of Annals takes an up-close look at solutions for eliminating health care inequalities in the United States, a central goal of the Department of Health and Human Services' Healthy People 2010 initiative. A cluster of articles examines health care disparities on many levels – from the conceptual framework to that of the individual patient experience. Collectively, the authors challenge policy makers to stop looking for simple, single-level solutions to the unfairness in the delivery of health care, calling for a long-term approach that bridges policies, systems, practices, individuals and communities.
The July/August 2003 issue also features the U.S. Preventive Services Task Force recommendation and rationale for measures primary care physicians can take to increase breastfeeding rates in the United States, also a goal of the Healthy People 2010 initiative.
In This Issue:
*U.S. Preventive Services Task Force Issues New Breastfeeding Recommendation*
The U.S. Preventive Services Task Force releases new recommendations for measures primary care providers can take to support and encourage breastfeeding among new mothers. In its statement, the USPSTF recommends the use of structured educational breastfeeding classes and behavioral counseling programs to promote breastfeeding.
The USPSTF found evidence that programs combining breastfeeding education with behaviorally oriented counseling are associated with increased rates of breastfeeding initiation and its continuation for up to three months. The USPSTF also found evidence that providing ongoing support for patients, through in-person visits or telephone contacts with providers or counselors, increased the proportion of women continuing breastfeeding for up to six months.
The USPSTF found insufficient evidence to recommend for or against the following interventions to promote breastfeeding: brief education and prevention counseling by primary care providers during routine office visits, peer counseling when used alone, and written materials.
Behavioral Interventions to Promote Breastfeeding: Recommendations and Rationale
By the U.S. Preventive Services Task Force
Click here to view a pdf of the complete article.
Education and Support Programs Shown to Improve Breastfeeding Rates
To assist the U.S. Preventive Services Task Force in developing new recommendations for primary care-based interventions to improve breastfeeding rates, Guise and colleagues conducted a systematic review of related studies conducted between 1966 and 2001 to determine the effectiveness of counseling, behavioral, and environmental interventions.
The researchers found that education sessions that review the benefits of breastfeeding, principles of lactation, myths, common problems, solutions and skills training appear to have the greatest single effect on breastfeeding rates. The researchers also found that the common practice of providing patients with written materials and discharge packets were not effective in prompting breastfeeding. In fact, discharge packets, especially those containing promotional materials with or without formula samples, were found to have a detrimental effect.
The Effectiveness of Primary Care-Based Interventions to Promote Breastfeeding: Systematic Evidence Review and Meta-Analysis for the U.S. Preventive Services Task Force
By Jeanne-Marie Guise, M.D., M.P.H., et al
Click here to view a pdf of the complete article.
Americans with Health Insurance and a 'Medical Home' Receive Higher Rates of Health Care
Americans with a usual source of care and health insurance are more likely to receive health care services than people who have neither, according to this study by Fryer and colleagues. The analysis expands the well-known ecology of medical care model to quantify how the location of medical care delivery differs depending on a number of sociodemographic characteristics, including age, sex, race, ethnicity, income, education, insurance, location of residence, and having a usual source of care.
The study found that lack of insurance is associated with less care in all settings except the emergency department and that not having a "medical home" (a particular doctor's office, clinic or other place a person routinely goes to for medical care) is related to lower rates of care in all health care settings. Additionally, the study found that the frequency and location of health care delivery varies substantially with sociodemographic characteristics. The results provide policy makers with a framework for considering future health care policy options and might be helpful in conceptualizing system redesign solutions to health care disparities.
Variation in the Ecology of Medical Care
By George E. Fryer, Jr., Ph.D., et al
Click here to view a pdf of the complete article.
Study Finds that People with Less Education Benefit from HMO Participation
HMO participation may help reduce the large disparities in health care for people of lower economic status, according to this study by Fiscella and colleagues. Through a cross-sectional analysis, the researchers found that respondents with less education were significantly less likely to have had a physician visit, mental health visit, mammogram or influenza vaccination in the past year. Interestingly, however, they also found that membership in an HMO significantly reduced these preventive care disparities.
In particular, the analysis showed that HMO members with less than 12 years of education received services at levels comparable to non-HMO respondents with more education. In their discussion, the authors suggest that future policies to eliminate inequalities in health care should consider the salutary effect of HMOs, which by virtue of their population focus and reporting, are well-positioned to address disparities in care.
Do HMOs Affect Educational Disparities In Health Care?
By Kevin Fiscella, M.D., M.P.H., et al
Click here to view a pdf of the complete article.
Nonphysician Primary Care Clinicians and Family Physicians Most Likely to Care for the Underserved
In the first study to compare the geographic distribution and patient populations of clinicians across the different primary care disciplines, Grumbach and colleagues found that a higher percentage of physician assistants, nurse practitioners, and family physicians care for underserved populations than do internists, pediatricians, and obstetricians-gynecologists.
Based on the survey results from California and Washington, the authors suggest that the continued maldistribution of primary care clinicians should be addressed through federal policies that continue to support successful training grant programs, such as Title VII and VIII, and through policies that provide incentives to training programs that prepare clinicians to practice in underserved communities.
Who is Caring for the Underserved? A Comparison of Primary Care Physicians and Nonphysician Clinicians in California and Washington
By Kevin Grumbach, M.D., et al
Click here to view a pdf of the complete article.
Racial Concordance Not Shown to Influence Children's Primary Care Experiences
In contrast to studies among adults, patient-provider race/ethnicity concordance was not found to be associated with parent-reported primary care experiences of children, according to this study by Stevens and colleagues.
The community-based survey of parents of elementary school children, aged 5 to 12 years, indicated that racial/ethnic concordance was not important for the parent's assessment of the accessibility, utilization, interpersonal relationship, and comprehensiveness of care. Additionally, the researchers found that having a concordant relationship did not reduce disparities in primary care experiences between minorities and whites. The researchers point out that these preliminary findings call into question simplistic solutions to disparities, such as matching the race/ethnicity of the clinician to that of the patient.
Patient-Provider Racial and Ethnic Concordance and Parent Reports of the Primary Care Experiences of Children
By Gregory D. Stevens, Ph.D., et al
Click here to view a pdf of the complete article.
Filipino Americans Heightened Bodily Awareness May Help Guide Effective Treatment
Through a rigorous qualitative study of 85 Filipino Americans, Becker found that the unique ways in which Filipino Americans combine attention to the body, values of balance and harmony, and emphasis on social well-being result in a heightened attention to bodily processes.
This emphasis on bodily awareness among Filipino Americans offers clinicians a unique opportunity utilize this strength to enhance chronic illness management plans. Becker suggests that awareness of culture-specific traditions can provide clinicians with insights into how best to help patients understand their illnesses and incorporate illness management plans into their lives.
Cultural Expressions of Bodily Awareness Among Chronically Ill Filipino Americans
By Gay Becker, Ph.D.
Click here to view a pdf of the complete article.
Annals of Family Medicine Publishes New U.S. Preventive Services Task Force Recommendations to Promote Breastfeeding
LEAWOOD, Kan. – The U.S. Preventive Services Task Force (USPSTF) today released new recommendations for measures primary care providers can take to support and encourage breastfeeding. The new recommendations and the systematic evidence-based review on which the USPSTF statement is based are published in the July/August 2003 issue of Annals of Family Medicine.
The newly published USPSTF guidelines recommend structured breastfeeding education and behavioral counseling programs to improve breastfeeding. In its review, the USPSTF found evidence that intervention programs combining educational classes with behaviorally oriented counseling are associated with increased rates of breastfeeding initiation and its continuation for up to three months. The USPSTF also found evidence that providing ongoing support for patients, through in-person visits or telephone contacts with providers or counselors, increased the proportion of women continuing to breastfeed for up to six months.
The USPSTF found insufficient evidence to recommend for or against the following interventions to promote breastfeeding: brief education and prevention counseling by primary care providers during routine office visits, peer counseling when used alone, and written materials.
An overwhelming body of evidence suggests that breast milk provides the most complete form of nutrition for infants and offers a range of benefits for both infant and maternal health. Despite this strong evidence, current U.S. breastfeeding rates, particularly among certain vulnerable populations, including low-income and minority populations, fall short of national goals.
National data from 2001 indicate that 58 percent of low-income mothers and 53 percent of African-American mothers initiate breastfeeding. By six months only 21 percent of low-income and 22 percent of African-American mothers continued breastfeeding. These rates compare with overall rates of 69.5 percent of new mothers who initiated breastfeeding and 32.5 percent who were still breastfeeding at six months.
Recognizing the health benefits of breastfeeding, the Department of Health and Human Services' Healthy People 2010 initiative set a goal of having 75 percent of mothers breastfeeding immediately after having a baby, 50 percent at six months and 25 percent at one year.
"We hope that these recommendations will help women and their clinicians understand which kinds of programs are most helpful, and will help ensure they become more widely available for pregnant women," said Task Force Chair, Alfred O. Berg, M.D., M.P.H., who is also Chair of the Department of Family Medicine at the University of Washington in Seattle. "In addition, there is a need for further studies about how clinicians and peer counselors can play a more significant role in encouraging women to breastfeed."
While the programs reviewed by the Task Force did not all take place in primary care clinics, the Task Force highlighted the important role primary care clinicians, such as family physicians, obstetricians and nurses in referring pregnant women to breastfeeding programs to ensure they begin and continue to breastfeed.
Also included in the July/August issue of Annals is the systematic evidence-based review by Jeanne-Marie Guise, M.D., M.P.H., and colleagues on which the USPSTF statement is based. The review, which analyzed the results of 35 related studies conducted between 1966 and 2001, found that educational programs, inclusive of individual instruction sessions or group classes with structured content, had the greatest positive effect of any single intervention on both initiation and short-term duration of breastfeeding.
"Our findings challenge hospitals and practices to make breastfeeding classes more accessible to patients," Guise said. "To improve breastfeeding rates, we must first begin by identifying and removing any existing barriers that might prevent mothers from receiving breastfeeding education and support services."
In their review, Guise and colleagues also found that support programs, conducted in person or over the telephone by lactation consultants, nurses or peer counselors, significantly increased short- and long-term breastfeeding duration.
In contrast, the researchers found that written materials, including informational pamphlets and booklets, were not effective in increasing initiation or duration of breastfeeding. The use of commercial discharge packets, which often contain samples and coupons for formula, was shown to significantly reduce exclusive breastfeeding.
The recommendations and review can be accessed on the Annals of Family Medicine Web site at www.annfammed.org. Access to these and other articles contained in the journal is free of charge.
Annals of Family Medicine is a peer-reviewed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care discipline. Launched in May 2003, the journal is sponsored by six family medical organizations, including the American Academy of Family Physicians (AAFP), the American Board of Family Practice (ABFP), the Society of Teachers of Family Medicine (STFM), the Association of Departments of Family Medicine (ADFM), the Association of Family Practice Residency Directors (AFPRD) and the North American Primary Care Research Group (NAPCRG). The journal is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. A board of directors with representatives from each of the sponsoring organizations oversees Annals. Complete editorial content and interactive discussion groups can be accessed free of charge on the journal's Web site, http://www.annfammed.org.
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The Annals of Family Medicine