Let their voices be heard: Understanding the barriers to seeking early prenatal care for low-income non-Hispanic Black women

Background: Receipt of early prenatal care, care during the first three months of pregnancy, is the standard in the United States. Sixty percent of non-Hispanic Black women who had a live birth in the Sunnyside community of Houston did not obtain early prenatal care in 2009. ^ This study's aims were to: 1) Describe the barriers to obtaining early prenatal care in non-Hispanic Black women who live in the Sunnyside community of Houston; and, 2) Describe the actions that could encourage non-Hispanic Black women who live in the Sunnyside Community to obtain early prenatal care. The goal was to provide information to organizations that promote early prenatal care use in non-Hispanic Black women in Harris County that may aid in developing interventions. ^ Methods: The Participatory Learning for Action rapid assessment qualitative method was used in a group setting to answer the research questions on behalf of women in the community. Women who participated in the group sessions also participated in an in-depth interview. Key informants who work in the community with pregnant women, or promote the use of prenatal care services, were also interviewed. An inductive analysis of the data was conducted to identify common themes that address the study's aims. ^ Results: Aim 1: Group participants identified fear of the reaction from family and/or the baby's daddy and shame, not having insurance or money, and lack of knowledge of the pregnancy and resources as the top three barriers to early prenatal care for women in the community. Aim 2: Group participants stated that to help women to overcome these barriers, communication, awareness and support; help, resources and services; and information and early education are needed. Participant in-depth interviewees echoed the themes of fear of the reaction from family and/or the baby's daddy and not knowing of the pregnancy. Key informants mentioned these themes as well, though not at the same priority level. Participants and key informants also mentioned similar themes for helping women to overcome barriers to early prenatal care. ^ Conclusion: A comprehensive approach is needed to improve early prenatal care use in the Sunnyside community. Education efforts must include all members of the community, young and old, to promote support for pregnant women. Community members must be a part of the process for developing education campaigns. Engaging the community builds a relationship with organizations that serve the community, which may promote use of the organizations' services, and build trust with the community. All efforts must be ongoing so that women and men of all ages in the community understand the importance of prenatal care and support women obtaining care early in the pregnancy.^

Teaching safety at a summer camp: Evaluation of a children's fire safety curriculum in an urban community setting

Objectives: The purpose of this study was to evaluate the effectiveness of the Danger Rangers Fire Safety Curriculum in increasing the fire safety knowledge of low-income, minority children in pre-kindergarten to third grade in Austin, TX during a summer day camp in 2007.^ Methods: Data was collected from child participants via teacher and researcher administered tests at pretest, posttest (immediately after the completion of the fire safety module), and at a 3 week follow-up to asses retention. In addition, a self-administered questionnaire was collected from parents pre- and post-intervention to assess home-related fire/burn risk factors. Paired t-tests were conducted using STATA 12.0 to evaluate pretest, posttest, and retention test mean scores as well as mean fire safety rules listed by grade group. McNemar's test was used to determine if there was a difference in fire-related risk factors as reported by the parents of the participants before and after the intervention. Only those who had paired data for the tests/surveys being compared were included in the analysis.^ Results: The first/second grade group and the third grade group scored significantly higher on fire safety knowledge on the posttest compared to the pretest (p<0.0001 for both groups). However, there was no significant change in knowledge scores for the pre-kindergarten to kindergarten group (p=0.14). Among the first/second grade group, knowledge levels did not significantly decline between the posttest and retention test (p=0.25). However, the third grade group had significantly lower fire safety knowledge scores on the retention test compared to the posttest (p<0.001). A similar increase was seen in the amount of fire safety rules listed after the intervention (p<0.0001 between pre and posttest for both the first/second grade and third grade groups), with no decline from the posttest to the retention test (p=0.50) for the first/second grade group, but a significant decline in the third grade group (p=0.001). McNemar's chi-square test showed a significant increase in the percentage of participants' parents reporting smoke detector testing on a regular basis and having a fire escape plan for their family after the intervention (p=0.01 and p<0.0001, respectively). However, there was no significant change in the frequency of reports of the child playing in the kitchen while the parent cooks or the house/apartment having a working smoke detector.^ Conclusion: We found that general fire safety knowledge improved and the number of specific fire safety rules increased among the first to third grade children who participated in the Danger Rangers fire safety program. However, it did not significantly increase general fire safety knowledge among the pre-k/k group. This study also showed that a program targeted towards children has the potential to influence familial risk factors by proxy. The Danger Rangers Fire Safety Curriculum should be further evaluated by conducting a randomized controlled trial, using valid measures that assess fire safety attitudes, beliefs, behaviors, as well as fire/burn related outcomes.^

Culminating experience: Initiation of cholinesterase inhibitors in an inpatient setting

We examined the practice of initiating Cholinesterase Inhibitors (ChEI) in a Veterans Affairs Medical Center. Patients hospitalized in FY 2008 and prescribed ChEI were identified. We reviewed electronic medical records, comparing those started on ChEI during hospitalization with those continuing ChEI from outpatient status. Of 282 patients receiving ChEI during hospitalization, 15.6% (44) were new-starts and 84.3% (238) were continuing medication. Median length of stay was 16 days in new-starts vs. 6 days in continuation patients (P<0.05). 38.6% new-starts were also treated for infection, which is a delirium risk factor. Chart review also suggested possible treatment for delirium by initiation of benzodiazepines and antipsychotics in 11.4% and 22.7% new-starts respectively. We observed a substantive practice of initiating ChEIs in hospitalized elderly who were at risk of delirium. Though there was no difference in 30-day mortality and readmission rates, new-starts were more likely to have a prolonged hospital stay than continuation patients.^

The assumptions and effects of conservative procedures in low -dose risk assessment for setting safety standards

Conservative procedures in low-dose risk assessment are used to set safety standards for known or suspected carcinogens. However, the assumptions upon which the methods are based and the effects of these methods are not well understood.^ To minimize the number of false-negatives and to reduce the cost of bioassays, animals are given very high doses of potential carcinogens. Results must then be extrapolated to much smaller doses to set safety standards for risks such as one per million. There are a number of competing methods that add a conservative safety factor into these calculations.^ A method of quantifying the conservatism of these methods was described and tested on eight procedures used in setting low-dose safety standards. The results using these procedures were compared by computer simulation and by the use of data from a large scale animal study.^ The method consisted of determining a "true safe dose" (tsd) according to an assumed underlying model. If one assumed that Y = the probability of cancer = P(d), a known mathematical function of the dose, then by setting Y to some predetermined acceptable risk, one can solve for d, the model's "true safe dose".^ Simulations were generated, assuming a binomial distribution, for an artificial bioassay. The eight procedures were then used to determine a "virtual safe dose" (vsd) that estimates the tsd, assuming a risk of one per million. A ratio R = ((tsd-vsd)/vsd) was calculated for each "experiment" (simulation). The mean R of 500 simulations and the probability R $<$ 0 was used to measure the over and under conservatism of each procedure.^ The eight procedures included Weil's method, Hoel's method, the Mantel-Byran method, the improved Mantel-Byran, Gross's method, fitting a one-hit model, Crump's procedure, and applying Rai and Van Ryzin's method to a Weibull model.^ None of the procedures performed uniformly well for all types of dose-response curves. When the data were linear, the one-hit model, Hoel's method, or the Gross-Mantel method worked reasonably well. However, when the data were non-linear, these same methods were overly conservative. Crump's procedure and the Weibull model performed better in these situations. ^

State rate -setting in conjunction with Medicare prospective payment: The effects of the Maine program

Maine implemented a hospital rate-setting program in 1984 at approximately the same time as Medicare started the Prospective Payment System (PPS). This study examines the effectiveness of the program in controlling cost over the period 1984-1989. Hospital costs in Maine are compared to costs in 36 non rate-setting states and 11 other rate-setting states. Changes in cost per equivalent admission, adjusted patient day, per capita, admissions, and length of stay are described and analyzed using multivariate techniques. A number of supply and demand variables which were expected to influence costs independently of rate-setting were controlled for in the study. Results indicate the program was effective in containing costs measured in terms of cost per adjusted patient day. However, this was not true for the other two cost variables. The average length of stay increased during the period in Maine hospitals indicating an association with rate-setting. Several supply variables, especially the number of beds per 1,000 population were strongly associated with the cost and use of hospitals. ^

Geologic-hydrologic setting and surface sedimentology in the Persian Gulf

1. Morphology and sedimentation The deepest parts of the Persian Gulf lie off the Iranian coast. Several swells separate the Persian Gulf into the Western Basin, the Central Basin and the Strait of Hormuz, which leads without noticeable morphological interruption onto the Biaban Shelf; the latter gradually drops off towards the continental slope, which itself has a strongly subdivided morphology. The sediment distribution in the Western Basin runs parallel to the basin's axis to a depth of 50 -60 m. This is caused by the shallow and uniform slope of the Iranian coast into the Western Basin, by clear exposure of the area to the Shamal-Winds and by tidal currents parallel to the basin's axis. Most other parameters also show isolines parallel to the coast line. Data from the sediment analyses show a net transport which extends out along the Central Swell: coarse fraction > 63 µ, total carbonate content, carbonate in fine fractions < 2 µ, 2-6 µ and 20-63 µ, calcite-aragonite ratios in the fine fractions 2-6 µ and 20-63 µ and quartz-dolomite ratios in fine fraction 2-6 µ. At least the uppermost 10-40 m of this sediment is late Holocene. This implies sedimentation rates of several meters per 1000 years. The slope from the Iranian coast into the Central Basin (max. depth 100 m) is generally steeper, with interspersed islands and flats. Both facts tend to disturb a sediment dustribition parallel to the basin's axis over extensive areas and may preclude any such trend from being detected by the methods and sample net used. The spatial distribution of the coarse fraction, however, seems to indicate sediment transport at greater water depths perpendicular to the basin's long axis and along the steepest gradients well into the Central Basin. The flats of the Central Basin have a sediment cover distinctly different from those of the deeper basin areas. Characteristic parameters are the extremely high percentages of coarse grained sediments, total content of carbonate CO2 over 40, low total organic carbon content, (however values are high if calculated on the basis of the < 63 µ fraction), low total N-content, and low C/N ratios. These characteristics probably result from the absence of any terrigenous material being brought in as well as from exposure to wave action. Finest terrigenous material is deposited in the innermost protected part of the Hormuz Bay. In the deep channel cut into the Biaban Shelf which carries the Persian Gulf out-flow water to the Indian Ocean, no fine grained sediment is deposited as shown by grain size data. 2. Geographic settings and sedimentation Flat lands border the Arabian coast of the Persian Gulf except for the Oman region. The high and steep Zagros Mountains form the Iranian coastline. Flat topography in combination with generally low precipitation precludes fluviatile sediment being added from the South. Inorganic and biogenic carbonates accumulating under low sedimentation rates are dominant on the shallow Arabic Shelf and the slopes into the Western and Central Basins. The fluviatile sediment brought in from the Iranian side, however decisively determine the composition of the Holocene sediment cover in the Persian Gulf and on the Biaban Shelf. Holocene sediments extend 20-30 km seaward into the Western Basin and about 25 km on to the Biaban Shelf. As mentioned before, sedimentation rates are of several meters/1000 years. The rocks exposed in the hinterland influence the sediments. According to our data the Redbeds of the Zagros Mountains determine the colour of the very fine grained sediments near the Iranian Coast of the Persian Gulf. To the West of Hormuz, addition of carbonate minerals is particularly high. Dolomite and protodolomite, deposited only in this area, as well as palygorskite, have proven to be excellent trace minerals. To the East of Hormuz, the supply of terrigenous carbonates is considerably lower. Clay minerals appear to bring in inorganically bound nitrogen thus lowering the C/N ratio in these sediments especially off river mouths. 3. Climate and sedimentation The Persian Gulf is located in a climatically arid region. This directly affects sedimentation through increased wind action and the infrequent but heavy rainfalls which cause flash floods. Such flash floods could be responsible for transporting sedheats into the Central Basin in a direction perpendicular to the Gulf's axis. Eolian influx is difficult to asses from our data; however, it probably is of minor importance from the Iranian side and may add, at the most, a few centimeters of fine sediment per 1000 years. 4. Hydrology and sedimentation High water temperatures favor inorganic carbonate precipitation in southern margin of the Gulf, and probably on the flats, as well as biogenic carbonate production in general. High evaporation plus low water inflow through rivers and precipitation cause a circulation pattern that is typical for epicontinental seas within the arid climate region. Surface water flows in from the adjoining ocean, in this case the Indian Ocean and sinks to the bottom of the Persian Gulf mainly in the northern part of the Western Basin, on the "Mesopotamischer Flachschelf" ard probably in the area of the "Arabischer Flachschelf". This sinking water continually rejuvenates the bottom out-flow water. The inflowing surface water from the Indian Ocean brings organic matter into the Persian Gulf, additional nutrients are added by the "fresh" upwelling waters of the Gulf of Oman. Both nutrients and organic matter diminish very rapidly as the water moves into the Persian Gulf. This depletion of nutrients and organic matter is the reasonfor generally low organic carbon contents of the Persian Gulf sediments. The Central Swell represents a distinct boundary, to the west of which the organic carbon content are lower than to the east when sediment samples of similar grain size distribution are compared. The outflow carries well oxygenated water over the bottom of the Persian Gulf and the resulting oxidation further decreases the content of organic matter. In the Masandam-Channel and in the Biaban-Shelf channel, the outflowing water prevents deposition of fine material and transports sediment particles well beyond the shelf margin. The outflowing water remains at a depth of 200-300 m depending on its density and releases ist suspending sediment load to the ocean floor, irrespectative of the bottom morphology. This is reflected in several parameters in which the sediments from beneath the outflow differ from nearby sediments not affected by the outflowing water. High carbonate content of total samples and of the individual size fraction as well as high aragonite and dolomite contents of individual size fractions characterize the sediment beneath the outflowing water. The tidal currents, which avt more or less parallel to the Gulf's axis, favor mixing of the water masses, they rework sediments at velocities reported here. This fact enlarges to a certain degree the extent of our interfaces which are based on only a few sample points (Persian Gulf and Biaban Shelf one sample per 620 km**2, continental slope one sample per 1000 km**2). The water on the continental slope shows and oxygen minimum at 200-1200 m which favors preservation of organically-bound carbon in the sediment. The low pH-values may even permit dissolution of carbonate minerals.

Major, trace element and XRF data for sediments and fish tooth samples, from a shallow marine setting with varying redox conditions (Site U1356, Wilkes Land Margin, E.Antarctica)

Fossil fish teeth from pelagic open ocean settings are considered a robust archive for preserving the neodymium (Nd) isotopic composition of ancient seawater. However, using fossil fish teeth as an archive to reconstruct seawater Nd isotopic compositions in different sedimentary redox environments and in terrigenous-dominated, shallow marine settings is less proven. To address these uncertainties, fish tooth and sediment samples from a middle Eocene section deposited proximal to the East Antarctic margin at Integrated Ocean Drilling Program Site U1356 were analyzed for major and trace element geochemistry, and Nd isotopes. Major and trace element analyses of the sediments reveal changing redox conditions throughout deposition in a shallow marine environment. However, variations in the Nd isotopic composition and rare earth element (REE) patterns of the associated fish teeth do not correspond to redox changes in the sediments. REE patterns in fish teeth at Site U1356 carry a typical mid-REE-enriched signature. However, a consistently positive Ce anomaly marks a deviation from a pure authigenic origin of REEs to the fish tooth. Neodymium isotopic compositions of cleaned and uncleaned fish teeth fall between modern seawater and local sediments and hence could be authigenic in nature, but could also be influenced by sedimentary fluxes. We conclude that the fossil fish tooth Nd isotope proxy is not sensitive to moderate changes in pore water oxygenation. However, combined studies on sediments, pore waters, fish teeth and seawater are needed to fully understand processes driving the reconstructed signature from shallow marine sections in proximity to continental sources. This article is protected by copyright. All rights reserved.