A qualitative assessment of structural barriers to prenatal care and congenital syphilis prevention in Kern County, California

Chan, Elaine; Smullin, Carolyn; Clavijo, Stephanie; Papp-Green, Melissa; Park, Eunhee; Nelson, Marlene; Giarratano, Gloria; Wagman, Jennifer A.

doi:10.1371/journal.pone.0249419

Cited by 27 publications

(37 citation statements)

References 13 publications

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“…Each of these social determinants has been associated with reporting more sexual partners, engaging in condomless sex, and having a higher risk of adolescent pregnancy, HIV, and/or other STIs [ 20 , 21 , 22 , 23 , 24 ]. SDH such as lack of access to healthcare (including pre-natal care), transportation challenges, poverty, low health literacy, and lower educational attainment have also specifically been reported among individuals with syphilis [ 25 , 26 , 27 ].…”

Section: Discussionmentioning

confidence: 99%

Geospatial Social Determinants of Health Correlate with Disparities in Syphilis and Congenital Syphilis Cases in California

et al. 2022

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Syphilis and congenital syphilis (CS) are increasing in California (CA). From 2015 through 2019, for example, CA cases of early syphilis among reproductive-age females (15–44) and CS each increased by >200%. Certain populations—including people experiencing homelessness, using drugs, and/or belonging to certain racial/ethnic groups—have been disproportionately impacted. We hypothesized that geospatial social determinants of health (SDH) contribute to such health inequities. To demonstrate this, we geospatially described syphilis in CA using the Healthy Places Index (HPI). The HPI is a composite index that assigns a score to each CA census tract based on eight socioeconomic characteristics associated with health (education, housing, transportation, neighborhood conditions, clean environment, and healthcare access as well as economic and social resources). We divided CA census tracts into four quartiles based on HPI scores (with the lowest quartile having the least healthy socioeconomic and environmental conditions), then used 2013–2020 CA sexually transmitted diseases surveillance data to compare overall syphilis (among adults and adolescents) and CS case counts, incidence rates (per 100,000 population or live births), and incidence rate ratios (IRRs) among these quartiles. From 2013 to 2020, across all stages of syphilis and CS, disease burden was greatest in the lowest HPI quartile and smallest in the highest quartile (8308 cases (representing 33.2% of all incidents) versus 3768 (15.1%) for primary and secondary (P&S) syphilis; 5724 (31.6%) versus 2936 (16.2%) for early non-primary non-secondary (NPNS) syphilis; 11,736 (41.9%) versus 3026 (10.8%) for late/unknown duration syphilis; and 849 (61.9%) versus 57 (4.2%) for CS; all with p < 0.001). Using the highest HPI quartile as a reference, the IRRs in the lowest quartile were 17 for CS, 4.5 for late/unknown duration syphilis, 2.6 for P&S syphilis, and 2.3 for early NPNS syphilis. We thus observed a direct relationship between less healthy conditions (per HPI) and syphilis/CS in California, supporting our hypothesis that SDH correlate with disparities in syphilis, especially CS. HPI could inform allocation of resources to: (1) support communities most in need of assistance in preventing syphilis/CS cases and (2) reduce health disparities.

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Section: Discussionmentioning

confidence: 99%

Geospatial Social Determinants of Health Correlate with Disparities in Syphilis and Congenital Syphilis Cases in California

et al. 2022

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“…Lack of engagement in antenatal care and inadequate syphilis screening and treatment during antenatal care leads to a higher risk of congenital syphilis and consequent health losses both in children and mothers [ 24 ]. The burden of congenital syphilis is even higher among women with limited access to antenatal care and treatment for syphilis [ 33 , 34 ].…”

Section: Discussionmentioning

confidence: 99%

Estimation of the Lifetime Quality-Adjusted Life Years (QALYs) Lost Due to Syphilis Acquired in the United States in 2018

Lee

You

et al. 2022

Clinical Infectious Diseases

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Background The purpose of this study was to estimate the health impact of syphilis in the United States in terms of the number of quality-adjusted life years (QALYs) lost attributable to infections in 2018. Methods We developed a Markov model which simulates the natural history and management of syphilis. The model was parameterized by sex and sexual orientation (women who have sex with men, men who have sex with women[MSW], and men who have sex with men[MSM]), and by age at primary infection. We developed a separate decision tree model to quantify health losses due to congenital syphilis. We estimated the average lifetime number of QALYs lost per infection, and the total expected lifetime number of QALYs lost due to syphilis acquired in 2018. Results We estimated the average number of discounted lifetime QALYs lost per infection as 0.09 [0.03-0.19 95% uncertainty interval (UI)]. The total expected number of QALYs lost due to syphilis acquired in 2018 was 13,349[5,071-31,360]. While per-case loss was the lowest among MSM(0.06), MSM accounted for 47.7% of the overall burden. For each case of congenital syphilis, we estimated 1.79[1.43-2.16] and 0.06[0.01-0.14] QALYs lost in the child and the mother, respectively. We projected 2,332[1,871-2,825] and 79[17-177] QALYs lost for children and mothers, respectively, due to congenital syphilis in 2018. Conclusions Syphilis causes substantial health losses in adults and children. Quantifying these health losses in terms of QALYs can inform cost-effectiveness analyses and can facilitate comparisons of the burden of syphilis to that of other diseases.

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“…To understand the origins of the disparities we saw in prenatal care use and risk for syphilis infection in Kern County and East Baton Rouge Parish, we (previously) explored and reported on potential socioecological and structural explanations. These included differences in SES and ability to pay for out of-pocket health care costs, access to reliable and affordable transportation, access to healthcare insurance, sexual health literacy and gender equality [ 6 , 7 ]. It has been posited that patient preferences may also explain some disparities in health care use [ 37 ] and we, indeed, found perinatal patient’s health beliefs were related to their decisions about maternal health, prenatal care and STI testing and treatment.…”

Section: Discussionmentioning

confidence: 99%

“…Providers in our study unequivocally recognized the severity of the CS epidemics in their regions and expressed commitment to mitigating its impact on the vulnerable populations they served. Most had been in practice multiple years and were aware of the CDC and American College of Obstetricians and Gynecologists guidelines on screening, testing, and treating congenital syphilis [ 6 , 7 ]. Nonetheless, many gaps remain in pregnant people’s use of and adherence to prenatal care in Kern County and East Baton Rouge Parish, not unlike what has been reported throughout the U.S. [ 9 ].…”

Section: Discussionmentioning

confidence: 99%

“…We previously published setting-specific findings on providers’ and perinatal participant’s perspectives on congenital syphilis as well as social-ecological and structural barriers to prenatal care and maternal syphilis testing and treatment in Kern County [ 6 ] and Baton Rouge [ 7 ]. Consistent with evidence from other U.S. locations [ 8 , 9 ], we found an interplay of individual (e.g., socioeconomic status or SES), relationship (e.g., partner notification), community (e.g., sexual health education), and societal/structural factors (e.g., immigration policies and public health program funding) that either put people at risk for or protected them from acquiring or transmitting syphilis [ 6 , 7 ]. At the core of these determinants were a range of disparities, including racial and ethnic differences in risk for infection and access to prenatal care and treatment for syphilis - differences that were mirrored across the U.S.…”

Section: Introductionmentioning

confidence: 99%

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Understanding perinatal patient’s health preferences and patient-provider relationships to prevent congenital syphilis in California and Louisiana

Wagman

Park

Giarratano

et al. 2022

BMC Pregnancy Childbirth

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Background Congenital syphilis (CS) has reemerged as a global maternal and child health crisis. Kern County, California and East Baton Rouge Parish, Louisiana are among the highest CS morbidity regions in the United States. We previously reported on social-ecological and structural barriers to prenatal care and maternal syphilis testing and treatment in these two regions. The aim of this study was to examine perinatal patient’s health preferences and perceptions of patient-provider relationships in the prenatal care clinic setting. Methods Between May 2018 and January 2019 we conducted 20 in-depth qualitative interviews with prenatal providers and 8 focus group discussions with pregnant and postpartum individuals in Kern County and East Baton Rouge Parish. We applied an adapted health services framework to analyze participants’ understanding of health disparities and vulnerable populations; perinatal patient’s health and prenatal care preferences; and participants’ perspectives of clinical encounters in the context of prenatal care and maternal syphilis testing and treatment. Results Site-specific determinants of syphilis infection emerged but participants from both locations felt CS prevention efforts should be prioritized among youth, racial/ethnic minority populations, people experiencing socioeconomic limitations and people with other commonly occurring health conditions. Although perinatal patients expressed clear health preferences, they reported inconsistent receipt of respectful, patient-centered care. Inconsistencies were connected with limited ethnic and cultural competence among providers, and implicit, negative attitudes toward patients using substances, experiencing homelessness, or engaging in sex work. Providers clearly aimed to offer high quality prenatal care. However, some clinic and health systems level factors were thought to reduce positive and communicative patient-provider relationships, contributing to gaps in use of prenatal care and syphilis testing and treatment. Conclusions Our findings suggest that interventions tailored to address setting-specific determinants (including clinic and health system factors) of disparities in CS risk could improve pregnant people’s access to prenatal care and ensure they and their sex partners receive timely syphilis screening and treatment. We recommend all prenatal care providers receive training on how to identify and mitigate implicit biases and provide competent and compassionate patient-centered care.

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A qualitative assessment of structural barriers to prenatal care and congenital syphilis prevention in Kern County, California

Cited by 27 publications

References 13 publications

Geospatial Social Determinants of Health Correlate with Disparities in Syphilis and Congenital Syphilis Cases in California

Geospatial Social Determinants of Health Correlate with Disparities in Syphilis and Congenital Syphilis Cases in California

Estimation of the Lifetime Quality-Adjusted Life Years (QALYs) Lost Due to Syphilis Acquired in the United States in 2018

Understanding perinatal patient’s health preferences and patient-provider relationships to prevent congenital syphilis in California and Louisiana

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