Low-income women of reproductive age have greater rates of cardiovascular disease (CVD) risk factors compared with their higher income counterparts.¹ A study published by the current authors demonstrated that many low-income women accessing reproductive health services at a North Carolina health department Title X family planning clinic had CVD precursors (pre-hypertension, borderline high cholesterol, or prediabetes) or risk factors (smoking or obesity).² Optimizing low-income women’s health during reproductive years may impact their long-term health and may also prevent adverse pregnancy outcomes such as low birth weight, preterm deliveries, and birth defects.³

Title X is a federal program that provides subsidized contraceptive services for more than five million low-income patients annually, and health departments are major providers of Title X services.⁴ Most women who receive family planning services through Title X report that their family planning provider is also their usual source of health care.^2,5 Because Title X clinics routinely screen for CVD risk factors, such as hypertension, smoking and obesity, these clinics frequently identify CVD risk factors among low-income women.

Title X clinics are expected to refer women for conditions identified during family planning visits that require medical care, but for which the clinics may lack resources to treat, such as hypertension. While making referrals are a requirement of Title X funding, only a few studies have examined referral patterns in family planning clinic settings.^6,7 One study found that providers in those settings were more likely to refer women testing positive for human immunodeficiency virus when providers were aware of local available referral resources.⁶ Another study reported family planning patients were more likely to seek follow-up care for abnormal Papanicolaou (Pap) tests if they were told by their provider where to obtain the follow-up care.⁷

To our knowledge, no published studies have documented referral practices related to management of CVD risk factors identified in Title X settings. This study examines the outcomes of referrals for CVD risk factors (hypertension, diabetes, smoking, and obesity) among nonpregnant women receiving family planning services at a Title X clinic in North Carolina, and examines whether CVD risk factors improved one year later among women who screened positive.

Among the 462 women who were screened at enrollment, a total of 167 (36.2%) were rescreened at their subsequent annual visit between 12 and 22 months (median = 13) after study enrollment. Loss rates include 48 (10.4%) women who became pregnant and were ineligible for screening at the subsequent annual visit, 13 (2.8%) who declined participation, 32 (6.9%) who visited the family planning clinic 12–22 months after screening, but were missed by research staff and were not offered rescreening, and 202 (43.7%) who did not return for an annual visit within the study period. No statistically significant differences on baseline demographics or CVD risk factors were found between 167 women who were rescreened and 295 who were not (Table 1).

Of CVD risk factors identified at enrollment that met referral criteria [hypertension, n = 13 (2.8%); diabetes, n = 7 (1.5%)], 11 out of 20 (73.3%) were new diagnoses (Fig. 1). Of the 11 women with new diagnoses, formal referrals were made for 6 women (54.5%), informal referrals were made for 3 (27.3%), and 2 (18.2%) women were not referred. For the 11 newly diagnosed women, 6 referrals (54.5%) were made to the local federally qualified community health center (CHC), 2 (18.2%) were made to the local university medical center, and 1 (9.1%) was made to a clinic in a neighboring community. Among 11 women who met referral criteria, 2 (18.2%) completed referrals: one was the result of a formal referral to the university medical center and the other resulted from an informal referral to the neighboring community clinic.

Twenty-one women identified with hypertension at screening were rescreened. The maximum systolic BP detected was 160 mmHg and the maximum diastolic BP detected was 114 mmHg. The overall mean systolic BP decreased 7 mmHg (139 mmHg to 132 mmHg, p = 0.001) and diastolic BP decreased 7 mmHg (90 mmHg to 83 mmHg, p = 0.006) at rescreening among these women (Table 2). In sensitivity analyses that included all women who returned for a subsequent annual visit and had data on BP (n 165), mean systolic BP did not differ statistically between enrollment and the subsequent annual visit (119 mmHg at both visits, p = 0.983), but the overall mean diastolic BP decreased 2 mmHg at the subsequent annual visit (76 to 74 mmHg, p = 0.007).

Five women identified with diabetes at screening were rescreened. The overall mean hemoglobin A1c was slightly higher at rescreening but not statistically different compared with the screening visit (7.9% versus 7.5%, respectively, p = 0.640, Table 2). In sensitivity analyses that included all women who were rescreened and had data on A1c (n = 160), the overall mean A1c did not differ statistically between the screening and rescreening visits (6% at both visits, p = 0.820).

Among 148 women who reported smoking at enrollment, 129 (87.2%) received cessation counseling and 8 (5.4%) accepted tobacco quitline referrals. Of those referred, one accepted services and received multiple counseling sessions plus the nicotine patch, another woman declined services as she was already receiving quitline services, and six were unreachable. Of 148 smokers, 53 (35.8%) returned for their subsequent annual visit and 11 (20.9%) reported nonsmoking at that time (p < 0.001, Table 3). In a sensitivity analysis that included all women who were rescreened and had data on smoking (n = 165), prevalence of smoking was lower at rescreening (46/165, 27.9%) but not statistically different from smoking prevalence at screening (53/165, 32.1%, p = 0.071).

Among 188 women identified as obese at enrollment, 22 (11.7%) scheduled nutrition appointments, but only one attended. Six obese participants who returned for a subsequent annual visit lost weight and were no longer obese (Table 3). However, the mean weight significantly increased between enrollment (221 lbs.) and the subsequent annual visit (225 lbs.) among obese women who were rescreened (n = 70, p = 0.047). In a sensitivity analysis that included all women who returned for a subsequent annual visit and had data on weight (n = 165), the overall mean weight also increased from 175 to 181 lbs. between visits (p < 0.001).

Of women who were screened, approximately one-third were rescreened at their next annual family planning visit; more than half did not return to the clinic, declined participation, or were missed; and an additional 10% became pregnant. Most women who were newly diagnosed with hypertension or diabetes were offered referrals. However, only 2 of 11 women with newly diagnosed hypertension or diabetes completed referrals, even though the majority of referrals were formally facilitated by the health department.

Reported referral completion rates among similar populations of women who receive formal referrals for abnormal Pap tests are substantially higher. A study of Medicaid-enrolled family planning providers in Arkansas and Alabama found 62.4% of their patients reported receiving follow up care for an abnormal Pap test.⁷ Some women were treated on-site by their family planning providers, while others received external referrals. Among women who were not treated on-site but were referred for follow up, 40.5% completed the referrals.⁷

The difference in referral completion rates between our study and those reported by the aforementioned study of low-income family planning women⁷ is notable. An important difference between the two studies is the condition of interest. The earlier study examined follow up for cervical cancer screening. There is a culture that supports cancer screening and taking action for abnormal results from cancer screening tests, in part due to the perceived suffering generated by cancer.¹⁰ The same culture may not exist for other diseases and conditions, such as CVD risk factors, which may not be perceived by patients as debilitating or life threatening. In the absence of such a culture, it may be difficult to engage women in taking action for asymptomatic problems—such as hypertension. Moreover, follow up rates in the Pap test study⁷ were higher among women who were treated by the same family planning provider that did the screening, compared with those who were referred to other providers. It is possible that follow up for hypertension and diabetes would have been more successful if treated on-site rather than by referral.

Since Title X clinics are expected to treat on-site or make referrals to meet their low-income clientele’s additional health care needs,¹¹ the very low referral completion rates reported in this study are concerning. Screening for hypertension and smoking are quality standards of care for safe and effective use of some forms of contraception, particularly hormonal contraceptive methods. Screening for obesity and diabetes, as clinically indicated, is considered part of preconception care,³ which is a component of family planning services.¹¹ Therefore, understanding the outcomes of referrals made in these settings has important programmatic implications for Title X and other health care systems concerned with ensuring access to quality, comprehensive care.

Finding primary care providers who will accept referrals for uninsured and indigent patients can be challenging.¹² This barrier is particularly difficult for Title X family planning clinics, which often are located in resource-limited areas. Unlike many rural communities, Pitt County does not have this barrier, as there are multiple medical resources that could provide referral care for indigent patients with CVD risk factors, including a state-supported academic medical center and a federally qualified CHC. In our study, most women were referred to the CHC, which uses a standard sliding fee scale for low-income patients.

Referrals to telephone quitlines for smoking cessation pose no financial barriers to women, as quitlines are free and offer assistance that may not be available to uninsured smokers elsewhere.¹³ Unfortunately, in this study, most women who accepted telephone quitline referrals were later unreachable. On-the-spot interventions (e.g., prescriptions for pharmacotherapy) and same-day referrals may be more successful. Brief clinical interventions—such as five A’s cessation counseling— are effective⁹ and clinicians might consider incorporating these during family planning clinic visits, as was done at the health department. Smoking cessation might also increase if one-on-one counseling sessions with tobacco-cessation specialists were available, as was demonstrated by a Well-Integrated Screening and Evaluation for Women across the Nation (WISEWOMAN) program in Alaska among women aged 40–64 years.¹⁴ However, participation in counseling sessions and impact of cessation rates may differ between reproductive age and older women. Moreover, the additional cost and time required to incorporate these services into routine medical visits needs to be examined.

While health care access does not always translate into utilization,¹⁵ it is unknown why the majority of women with CVD risk factors in this study did not receive needed follow-up care. Implementation of electronic medical records may alert clinicians to noncompletion of referrals and trigger follow up on failed referrals when patients return to the clinic. Tangible solutions to patient-level reasons for noncompletion of referrals are less clear. For example, some research among similar populations suggests fatalism and having previous negative experiences with health care providers as reasons for nonuse of breast cancer screening when such care is available and accessible.¹⁶ Additionally, a recent systematic review reported that prioritizing clinic visits over the needs of family members and work was commonly reported by patients as a barrier to hypertension treatment and follow up.¹⁷ Finally, low referral completions in our study may be explained by financial and transportation barriers and delays in referral appointment dates.

Since the health department is the usual source of care for the majority of women in this sample,² it is also unclear why nearly half did not return for their subsequent annual visits. Low-income women of reproductive age, particularly those with young children, can have limited free time and competing priorities. Therefore, timely preventive health care visits may not rise to the top of the daily demands. However, interruption of contraceptive services is likely to result in unplanned pregnancies. Additionally, the discontinuity of care represented by the low rescreening rates presents challenges for providing preconception care and preventing unintended pregnancies—both of which are essential components of quality family planning services and Title X.¹¹ It is possible that rescreening rates would have been higher among this population if all women participating had the opportunity to be rescreened up to 18 months after the initial screening. Our rescreening period captured all women who were screened and rescreened 12–13 months later. However, women who were screened earlier during the interval of May 2011–February 2012 had longer to get rescreened than those who were screened later.

The limitations of the screening study were previously elucidated and included possible overestimation of hypertension prevalence, potential selection and recall bias, and the generalizability of results.² Although the rescreened sample constitutes only 36% of the initial sample of women who were screened at enrollment, women who were rescreened did not differ on baseline characteristics from those who were not rescreened. However, it is likely that we did not measure all characteristics that affect health care–seeking behavior. Finally, evaluating improvements among women who screened positive for CVD risk factors was limited by the small sample. Nevertheless, few published studies have examined outcomes of screening for CVD risk factors in women of reproductive age; therefore, this study contributes to that small literature.

Women attending Title X clinics are routinely screened for several CVD risk factors, but previous studies have not examined the outcomes of that screening. This study found that the majority of women with newly identified CVD risk factors received indicated referrals, but few women completed those referrals. Treating CVD risk factors can impact the long-term health of women and improve their pregnancy outcomes. Thus, research is needed to (1) improve understanding about the barriers and facilitators to receiving referral care for management of CVD risk factors among low-income women of reproductive age, (2) explore the feasibility of managing CVD risk factors on-site in Title X settings, and (3) identify best practices in managing these risk factors for women who screen positive in these settings.