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BACKGROUND: This study aims to understand how criminal-legal involved women from three U.S. cities navigate different health resource environments to obtain cervical cancer screening and follow-up care. METHODS: We conducted a cross-sectional study of women with criminal-legal histories from Kansas City KS/MO; Oakland, CA; and Birmingham, AL. Participants completed a survey that explored influences on cervical cancer prevention. Responses from all women with/without up-to-date cervical cancer screening and women with abnormal Pap testing who did/did not obtain follow-up care were compared. Proportions and associations were tested with chi-square or analysis of variance tests. Multivariable regression was performed to identify variables independently associated with up-to-date cervical cancer screening and reported as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: There were n = 510 participants, including n = 164 Birmingham, n = 108 Kansas City, and n = 238 Oakland women. Criminal-legal involved women in Birmingham (71.3%) and Kansas City (68.9%) were less likely to have up-to-date cervical cancer screening than women in Oakland (84.5%, p = 0.01). More women in Birmingham (14.6%) and Kansas City (16.7%) needed follow-up for abnormal Pap than women in Oakland (6.7%, p = 0.003), but there were no differences in follow-up rates. Predictors for up-to-date cervical cancer screening included access to a primary care provider (OR: 3.3, 95% CI: 1.4–7.7), health literacy (OR: 0.3, 95% CI: 0.2–0.7), and health behaviors, including avoiding tobacco (OR: 0.4, 95% CI: 0.1–0.9) and HPV vaccination (OR: 3.4, 95% CI: 1.0–10.9). CONCLUSIONS: Cervical cancer screening and follow-up varied by study site. The results suggest that patient level factors coupled with the complexity of accessing care in different health resource environments impact criminal-legal involved women's cervical cancer prevention behaviors.

The community health delivery system (CHDS) are vital agencies to the success of integration and the provision of services to improve the health and well-being of justice-involved women. Many agencies face barriers and challenges in providing services to vulnerable populations, such as justice-involved women, and, as a result, often offer individual rather than coordinator care. Thus, it is necessary to explore CHDS systemic barriers and challenges to identify opportunities for coordinated care. We conducted semi-structured interviews with 26 CHDS directors or designees to identify systemic barriers and challenges, organizational processes, experiences with vulnerable populations, services and programs, and care coordination and perceived women's barriers and challenges to the provision of services including decision-making processes and access. Qualitative analyses were used to construct thematic descriptions in five areas: (1) mental health as an unmet need, (2) financial constraints, (3) limited organizational capacity, (4) implicit bias, and (5) minimal cultural support of vulnerable populations.

The aim of this study was to understand COVID-19 vaccine perceptions and decision-making among a racially/ethnically diverse population of pregnant and lactating women in the Midwest. Pregnant female participants (N = 27) at least 18 years. or older living in the Midwest were recruited to participate in a maternal voices survey. A mix-methods approach was used to capture the perceptions of maternal voices concerning the COVID-19 vaccine. Participants completed an online survey on COVID-19 disease burden, vaccine knowledge, and readiness for uptake. A total of 27 participants completed the Birth Equity Network Maternal Voices survey. Most participants were African American (64%). Sixty-three percent intend to get the vaccine. Only 25% felt at-risk for contracting COVID-19, and 74% plan to consult their provider about getting the COVID-19 vaccine. At least 66% had some concerns about the safety of the vaccine. Participants indicated a willingness to receive the COVID-19 vaccine, especially if recommended by their provider. We found little racial/ethnic differences in perceptions of COVID-19 and low vaccine hesitancy.

Objectives: We profiled the health and health services needs of a sample of older adult women (age 50+) with criminal–legal system (CLS) involvement and compared them with younger women (age 18–49), also CLS-involved. Methods: Using survey data collected from January to June 2020 from adult women with CLS involvement in three US cities, we profiled and compared the older adult women with younger women on behavioral and structural risk factors, health conditions, and health services access and use. Results: One-third (157/510) were age 50+. We found significant differences ( p < .05) in health conditions and health services use: older women had more chronic conditions (e.g., hypertension and stroke) and more multimorbidity and reported more use of personalized care (e.g., private doctor, medical home, and health insurance). Discussion: Although older women with CLS involvement reported good access to health services compared with younger women, their chronic health conditions, multimorbidity, and functional declines merit attention.

Purpose: To assess effectiveness, 1-year post-intervention, of a program delivered in jails with women to improve cervical health literacy (CHL) and up-to-date Papanicolaou (Pap) screening. Design: Pre-post design to evaluate Pap screening and CHL effects 1 year after our original randomized wait-list control study. Setting: Surveys conducted in Kansas City, 2015 to 2017 (baseline in 2014). Participants: Adult women (n = 133). Intervention: One-week (10-contact-hour), small-group, CHL program. Measures: Surveys to assess CHL components and up-to-date Pap screening. Analysis: χ2 and t tests, followed by best-subsets logistic regression using sociodemographic and CHL components to fit an optimal model for up-to-date screening 1-year post-intervention. Results: 73% (133/182) women retained at 1-year. From pre-intervention, 6 of 8 CHL components improved (.01 > P > .001). Up-to-date Pap screenings increased over pre-intervention (72%-82%, P < .05). Best-subset model to predict up-to-date screening included age; public benefits; medical insurance; 5 CHL components (knowledge, benefits, barriers, seriousness, susceptibility). Conclusion: A brief intervention to promote cervical health literacy, delivered with women during a jail detention, can lead to sustained improvements in CHL and prevention practices.

Precision public health requires research that supports innovative systems and health delivery approaches, programs, and policies that are part of this vision. This study estimated the effects of health insurance mandate (HiM) variations and the effects of physician utilization on moderating colorectal cancer (CRC) screening rates. A time-series analysis using a difference-in-difference-in-differences (DDD) approach was conducted on CRC screenings (1997–2014) using a multivariate logistic framework. Key variables of interest were HiM, CRC screening status, and physician utilization. The adjusted average marginal effects from the DDD model indicate that physician utilization increased the probability of being “up-to-date” vs. non-compliance by 9.9% points (p = 0.007), suggesting that an estimated 8.85 million additional age-eligible persons would receive a CRC screening with HiM and routine physician visits. Routine physician visits and mandates that lower out-of-pocket expenses constitute an effective approach to increasing CRC screenings for persons ready to take advantage of such policies.

Background Over seven million imprisoned and jailed women are released into the community each year and many are ill-equipped to meet the challenges of re-integration. Upon release into their community, women are faced with uncertain barriers and challenges using community services to improve their health and well-being and reuniting with families. Few studies have identified and described the barriers of the community health delivery system (CHDS)- a complex set of social, justice, and healthcare organizations that provide community services aimed to improve the health and well-being (i.e. safety, health, the success of integration, and life satisfaction) of justice-involved women. We conducted a narrative review of peer-reviewed and gray literature to identify and describe the CHDS and the CHDS service delivery. Results Peer-reviewed and gray literature (n = 82) describing the CHDS organizations’ missions, incentives, goals, and services were coded in three domains, justice, social, and healthcare, to examine their service delivery to justice-involved women and their efforts to improve the health and well-being of justice-involved women. Conclusions We found that the CHDS is fragmented, identified gaps in knowledge about the CHDS that serves justice-involved women, and offer recommendations to reduce fragmentation and integrate service delivery aimed to improve the health and well-being of justice-involved women.

School nurses are often sources of health-care support for teens with sexually transmitted infections (STIs) and unintended pregnancies. However, providing prevention (e.g., condoms) and teaching technical skills (e.g., condom use) needed to reduce high-risk sexual behavior may require a change in perceptions and policies. This study used a cross-sectional study design to assess nurses’ perceptions of condom availability accompanied by sex education programs among high school nurses ( n = 87) in Kansas. Results showed that school nurses in this study supported condom availability, were comfortable providing condoms, and felt condom availability was within the scope of their job but were less likely to provide condoms because of external barriers. Common barriers include administration, parents, cost, community support, and policies. School nurses, by virtue of their access to the majority of Kansas’ adolescents, have the potential to provide sex education and tools such as condoms, so young people can prevent STIs and unintended pregnancies.

OBJECTIVES/GOALS: To characterize the various social and health trajectories of women released from jail, and how these trajectories influence women’s risky sexual and drug behaviors. To identify areas in which prevention programs and community interventions can be implemented to improve social and health outcomes. METHODS/STUDY POPULATION: The present study analyzes data collected as part of the sexual health empowerment (SHE Project) health literacy intervention. Participants were recruited from three county jails in the greater Kansas City area. At baseline, participants completed a survey that assessed participants’ sociodemographic characteristics and social histories prior to incarceration. Women were recruited between 2014-2016 and followed up annually after program completion to complete follow-up surveys to assess long-term health and social circumstances. The present study is a secondary analysis of baseline and follow-up data. Final analyses will include survey data from 126 women. RESULTS/ANTICIPATED RESULTS: In this study, we use Hobfoll’s Conservation of Resources (COR) Theory to conceptualize the impacts of stress on the social and health behaviors of justice-involved women in the years following release from jail. We hypothesize that “loss spirals”, a term coined by Stevan Hobfoll, creates psychological stress that drive justice-involved women to assume behaviors that will generate more resources and help to cope with the stress. We expect to find that women struggle to maintain ties to stable housing, employment, and support, which we believe to be central to “loss spirals.” Additionally, we expect to find that these “loss spirals” are associated with sexual and drug health risks. DISCUSSION/SIGNIFICANCE OF IMPACT: This study aims to define a succinct longitudinal timeline assessing biopsychosocial outcomes of women released from jail in order to improve prevention and intervention techniques for the improvement in social and health circumstances of women leaving jail and their reduction in recidivism.

Objectives. We estimated the effect of economic constraints on public health delivery systems (PHDS) density and centrality during 3 time periods, 1998, 2006, and 2012. Methods. We obtained data from the 1998, 2006, and 2012 National Longitudinal Study of Public Health Agencies; the 1993, 1997, 2005, and 2010 National Association for County and City Health Officials Profile Study; and the 1997, 2008, and 2011 Area Resource Files. We used multivariate regression models for panel data to estimate the impact of economic constraints on PHDS density and centrality. Results. Findings indicate that economic constraints did not have a significant impact on PHDS density and centrality over time but population is a significant predictor of PHDS density, and the presence of a board of health (BOH) is a significant predictor of PHDS density and centrality. Specifically, a 1% increase in population results in a significant 1.71% increase in PHDS density. The presence of a BOH is associated with a 10.2% increase in PHDS centrality, after controlling for other factors. Conclusions. These findings suggest that other noneconomic factors influence PHDS density centrality.

Although several states have implemented programs providing boxes for infant sleep, safe sleep experts express concern regarding the paucity of safety and efficacy research on boxes. The purpose of this study was to assess pregnant women’s perceptions regarding use of baby sleep boxes. A convenience sample was recruited from a community prenatal education program. Twenty-eight women were administered a brief semistructured interview about their knowledge of baby sleep boxes, opinions about the boxes, and questions they would have. For most (n = 15, 54%), this was their first pregnancy. Participants self-identified as white (43%), black (36%), Hispanic (18%), and “other” (4%). Ten subthemes emerged related to previous knowledge of boxes (useful for families in need, historic precedent in other countries), positive attributes (portable, compact, affordable, decorative), and negative attributes (low to ground, structural integrity/design, stability, stigma). Research on safety and efficacy could reduce concerns, but issues of stigma may persist.

Cancer is the second leading cause of death in the U.S and a source of large racial and ethnic disparities in population health. Policy development is a powerful but sometimes overlooked public health tool for reducing cancer burden and disparities. Along with other partners in the public health system, community- based organizations such as local cancer councils can play valuable roles in developing policies that are responsive to community needs and in mobilizing resources to support policy adoption and implementation. This paper examines the current and potential roles played by local cancer councils to reduce cancer burden and disparities. Responsive public health systems require vehicles for communities to engage in policy development. Cancer councils provide promising models of engagement. Untapped opportunities exist for enhancing policy development through cancer councils, such as expanding targets of engagement to include private-sector stakeholders and expanding methods of engagement utilizing the Affordable Care Act’s Prevention and Public Health Fund.

Context: Policy discussions about improving the U.S. health care system increasingly recognize the need to strengthen its capacities for delivering public health services. A better understanding of how public health delivery systems are organized across the United States is critical to improvement. To facilitate the development of such evidence, this article presents an empirical method of classifying and comparing public health delivery systems based on key elements of their organizational structure. Methods: This analysis uses data collected through a national longitudinal survey of local public health agencies serving communities with at least 100,000 residents. The survey measured the availability of twenty core public health activities in local communities and the types of organizations contributing to each activity. Cluster analysis differentiated local delivery systems based on the scope of activities delivered, the range of organizations contributing, and the distribution of effort within the system. Findings: Public health delivery systems varied widely in organizational structure, but the observed patterns of variation suggested that systems adhere to one of seven distinct configurations. Systems frequently migrated from one configuration to another over time, with an overall trend toward offering a broader scope of services and engaging a wider range of organizations. Conclusions: Public health delivery systems exhibit important structural differences that may influence their operations and outcomes. The typology developed through this analysis can facilitate comparative studies to identify which delivery system configurations perform best in which contexts.

We examined the effects of local health department (LHD) consolidations on the total and administrative expenditures of LHDs in Ohio from 2001 to 2011. We obtained data from annual records maintained by the state of Ohio and through interviews conducted with senior local health officials and identified 20 consolidations of LHDs occurring in Ohio in this time period. We found that consolidating LHDs experienced a reduction in total expenditures of approximately 16% (P = .017), although we found no statistically significant change in administrative expenses. County health officials who were interviewed concurred that their consolidations yielded financial benefits, and they also asserted that their consolidations yielded public health service improvements.

Public health encompasses a broad array of programs designed to prevent the occurrence of disease and injury within communities. But policy makers have little evidence to draw on when determining the value of investments in these program activities, which currently account for less than 5 percent of US health spending. We examine whether changes in spending by local public health agencies over a thirteen-year period contributed to changes in rates of community mortality from preventable causes of death, including infant mortality and deaths due to cardiovascular disease, diabetes, and cancer. We found that mortality rates fell between 1.1 percent and 6.9 percent for each 10 percent increase in local public health spending. These results suggest that increased public health investments can produce measurable improvements in health, especially in low-resource communities. However, more money by itself is unlikely to generate significant and sustainable health gains; improvements in public health practices are needed as well.

Geographic variation in health care spending within the United States has long been a source of policy concern because it implies large inefficiencies and inequities in resource use (Wennberg and Gittelsohn 1973). The greater-than-twofold differences in health care spending observed across U.S. communities persist after accounting for differences in medical care prices (Welch et al. 1993; Skinner and Fisher 1997;), socioeconomic status (SES), and illness burden (Wennberg and Cooper 1998; Fisher et al. 2000;). Moreover, several recent studies suggest that residents of high-spending regions do not enjoy superior health outcomes compared with their counterparts in low-spending regions (Fisher et al. 2003a,b;). Medical care represents only one class of resources used to improve health and control disease, and studies suggest that these resources account for only about half of the gains in life expectancy realized during the past half-century (Brown et al. 1991; Trust for America's Health [TFAH] 2006; Sensenig 2007;). By comparison, public health resources support activities designed to promote health and prevent disease and disability at the population level, such as efforts to monitor community health status, investigate and control disease outbreaks, educate the public about health risks and prevention strategies, enforce public health laws and regulations like those concerning tobacco use or food preparation, and inspect and assure the safety and quality of water, air, and other resources necessary for good health (Institute of Medicine [IOM] 1988). These activities may account for gains in health and life expectancy that are not attributable to medical care. As such, geographic variation in public health resources may contribute to gaps and inequities in population health. Relatively little is known, however, about the extent and nature of geographic variation in public health spending. Although no uniform system of accounts exists to track public health spending at national, state, or local levels, available estimates suggest that less than 5 percent of the nation's health-related spending is devoted to public health activities (Brown et al. 1991; TFAH 2006; Sensenig 2007;). Public health activities are supported through a patchwork of local, state, federal, and nongovernmental funding mechanisms that vary widely across states and communities (Gerzoff, Gordon, and Richards 1996; Gordon, Gerzoff, and Richards 1997; TFAH 2006;). These mechanisms give rise to large geographic disparities in spending for public health services. The National Association of State Budget Officers (NASBO) estimated that state governments' per-capita spending on public health activities varied by a factor of >30 in 2003, ranging from >U.S.$400 per person in Alaska and Hawaii to U.S.$200 per capita in 2005, with the median local public health agency spending about U.S.$30 per person (National Association of County and City Health Officials [NACCHO] 2006). On balance, very little empirical evidence exists about the extent and nature of geographic variation in public health spending (Carande-Kulis, Getzen, and Thacker 2007). The lack of uniform data on public health spending has hampered research on this topic. The NASBO and more recently the TFAH have used information from state budget documents to produce estimates of state governmental spending on public health activities, but differences in state accounting and reporting conventions cause significant errors and inconsistencies in estimates (NASBO 2005; TFAH 2006;). Other studies have classified the public health expenditures of individual state or local governments using standardized accounting protocols, but these individual assessments do not support systematic comparisons of spending across communities and over time (Barry et al. 1998; Budetti and Lapolla 2008;). Estimates of federal, state, and local governmental expenditures on public health activities are included in the National Health Expenditure Accounts maintained by the U.S. Centers for Medicare and Medicaid Services (CMS), using data collected by the U.S. Census of Governments. These estimates, however, are widely considered to be incomplete because they include expenditures for a relatively narrow set of governmental activities and because they exclude expenditures on personal health services commonly provided by public health agencies, such as immunizations, chronic disease screening, and communicable disease control (Sensenig 2007). Completely lacking in the literature are estimates of the resources expended on public health activities by nongovernmental organizations such as community hospitals, community-based organizations, health insurers, and employers (Mays, Halverson, and Kaluzny 1998; Mays et al. 2000;). This paper uses a recently compiled longitudinal dataset on local governmental public health agencies to examine how public health spending levels vary across communities and change over time. Following similar studies of variation in medical spending, we focus on three primary questions of interest: (1) what are the demographic, socioeconomic, and institutional characteristics of high-spending and low-spending communities? (2) What characteristics are associated with growth and decline in spending levels over time? (3) What types of communities are most likely to experience reductions in public health spending? Answers to these questions will help policy makers at all levels of government anticipate resource needs and make better decisions about how to allocate scarce public health resources. This study focuses on spending at the local level because local public health agencies—rather than their state and federal counterparts—assume primary responsibility for directly implementing public health activities in most communities (DeFriese et al. 1981; Halverson et al. 1996;). Most federal and state grants for public health activities, and significant private funding, are channeled through local public health agencies (Mays et al. 2004b; NACCHO 2006;). Moreover, these agencies frequently work to mobilize and coordinate the public health activities of other organizations in the community (Mays, Halverson, and Kaluzny 1998; IOM 2002;). As such, these agencies provide valuable settings in which to study the determinants and consequences of public health spending in the United States.

The authors review empirical studies published between 1990 and 2007 on the topics of public health organization, financing, staffing, and service delivery. A summary is provided of what is currently known about the attributes of public health delivery systems that influence their performance and outcomes. This review also identifies unanswered questions, highlighting areas where new research is needed. Existing studies suggest that economies of scale and scope exist in the delivery of public health services, and that key organizational and governance characteristics of public health agencies may explain differences in service delivery across communities. Financial resources and staffing characteristics vary widely across public health systems and have expected associations with service delivery and outcomes. Numerous gaps and uncertainties are identified regarding the mechanisms through which organizational, financial, and workforce characteristics influence the effectiveness and efficiency of public health service delivery. This review suggests that new research is needed to evaluate the effects of ongoing changes in delivery system structure, financing, and staffing.

Background: Prostate cancer is the most commonly diagnosed cancer and second leading cause of cancer death in the US among men. Although overall incidence and mortality has decreased over time, disparities still exist among racial/ethnic groups. Strategies to reduce disparities in cancer detection, treatment, and outcomes among racial/ethnic minorities and low-income patients have been gathering momentum with the introduction of patient navigation (PN) initiatives. The current advancement of medical knowledge and technology spurs a widening gap in healthcare delivery for racial/ethnical minorities and medically underserved populations for certain emerging state-of-the-art treatments. The controversy around the effectiveness of prostate-specific antigen (PSA) and digital rectal exam (DRE) as screening tools was cited as a possible reason for this information void, but research suggests that African American males rely on their physicians to recommend all needed tests/screenings. The study examined the current and potential roles of PN in the improvement of prostate cancer screenings among disadvantaged populations. Methods: A Longitudinal study design was conducted on males over 35 years of age to examine the role of patient navigation on equity of access to prostate cancer screening among disadvantaged populations since 2008 (n=1602). Patient's demographics, geographical location, PSA scores, and DRE scores, and the array of event types in which community engagement occurred were collected. Data were analyzed using comparison analyses. Results: Patient navigation allowed for greater utilization of health services among populations of rural origins (Urban: n=747; Rural: n=833). Mean PSA scores were within normal range, although mean PSA scores for non-whites residing in rural areas (1.45ng/mL) was slightly higher than non-whites in urban areas of the state (1.36ng/mL; p=0.03). The mean age was 54 years (Urban: 51 years; Rural: 56 years; p=0.001). Conclusions: Equity of access to cancer screenings among disadvantaged populations may be achieved with the utilization of patient navigation programs. Access to the health care system is a strong barrier which fosters disparities among disadvantaged populations. PN allows rural disadvantaged populations entry into the health care system at earlier stages, considering PSA as a proxy for disease. Health care reform lays the foundation for preventative programs such as patient navigation. Citation Format: Michael A. Preston, Katherine Glover-Collins, Dale Gray, Sharla Smith, Ronda Henry-Tillman. Healthcare reform: Closing the health disparities gap. Where does patient navigation belong? [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A91.