title: Multilevel analysis of the determinants of receipt of clinical preventive services among reproductive-age women.
abstract: BACKGROUND
  We investigated the impact of individual- and county-level contextual variables on women's receipt of a comprehensive panel of preventive services in a region that includes both urban and rural communities.
  
  
  METHODS
  Outcome variables were a screening and vaccination index (a count of Papanicolaou test, blood pressure check, lipid panel, sexually transmitted infections [STI] or HIV test, and influenza vaccination received in the past 2 years) and a preventivecounseling index (a count of topics discussed in the past 2 years: Smoking and tobacco, alcohol or drugs, violence and safety, pregnancy planning or contraception, diet/nutrition, and STIs). Contextual covariates from the Area Resource File (2004-2005) were appended to prospective survey data from the Central Pennsylvania Women's Health Study. Individual-level variables included predisposing, enabling, and need-based measures. Contextual variables included community characteristics and healthcare resources, including a measure of primary care physician (PCP) density specifically designed for this study of women's preventive care. Multilevel analyses were performed.
  
  
  RESULTS
  We found low overall use of preventive services. In multilevel models, individual-level factors predicted receipt of both screening and vaccinations and counseling services; significant predictors differed for each index. One contextual variable (PCP density) predicted receipt of screenings and vaccinations.
  
  
  CONCLUSIONS
  Women's receipt of preventive services was determined primarily by individual-level variables. Different variables predicted receipt of screening and vaccination versus counseling services. A contextual measure, PCP density, predicted receipt of preventive screenings and vaccinations. Individual variability in women's receipt of counseling services is largely explained by psychosocial factors and seeing an obstetrician-gynecologist.
authors.affiliation: Department of Medicine, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA. jmccallhosenfeld@hmc.psu.edu
authors.forename: Jennifer S
authors.initials: JS
authors.lastname: McCall-Hosenfeld
authors.forename: Carol S
authors.initials: CS
authors.lastname: Weisman
authors.forename: Fabian
authors.initials: F
authors.lastname: Camacho
authors.forename: Marianne M
authors.initials: MM
authors.lastname: Hillemeier
authors.forename: Cynthia H
authors.initials: CH
authors.lastname: Chuang
mesh_terms: D000293:Adolescent; D000328:Adult; D003376:Counseling / Q000706:statistics & numerical data; D005260:Female; D015438:Health Behavior; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006306:Health Surveys; D006801:Humans; D008403:Mass Screening / Q000706:statistics & numerical data; D008875:Middle Aged; D055361:Multilevel Analysis; D010414:Pennsylvania; D011159:Population Surveillance; D011314:Preventive Health Services / Q000706:statistics & numerical data*; D034121:Reproductive Health Services / Q000706:statistics & numerical data*; D012424:Rural Population / Q000706:statistics & numerical data; D012944:Social Support; D012959:Socioeconomic Factors; D014505:Urban Population / Q000706:statistics & numerical data; D014611:Vaccination / Q000706:statistics & numerical data; D055815:Young Adult