Diversity

Women and Health Committee: Featured Topics Archive

It is our mission to highlight and promote research, treatments and resources for women’s health. We will bring monthly features highlighting new, innovative and informative research relevant to women and women’s health accompanied by comments by the authors themselves and links for more information. Welcome to our archive of health topics!

Cancer screening in rural minorities

Feature Article: Bennett, K. J., Probst, J. C. and Bellinger, J. D. (2012). Receipt of cancer screening services: Surprising results for some rural minorities. The Journal of Rural Health, 28, 63-72.

Comment by the authors

At the South Carolina Rural Health Research Center, we strive to conduct policy-relevant research that examines health, health care access, and outcomes among rural minorities. We have studied a diversity of topics, ranging from preventive service delivery, hospital readmissions, uncompensated care, mental health, end-stage renal disease, adolescent health, and oral health. Our findings are communicated to the Office of Rural Health Policy (ORHP), a unit within the Health Resources Services Administration, US Department of Health and Human Services, which oversees many rural health policies, programs, and interventions with the intent of improving health among these populations.

The manuscript “Receipt of Cancer Screening Services: Surprising Results for Some Rural Minorities” was a derivate of a larger, ORHP-funded work, Health Disparities: A Rural-Urban Chartbook. The chartbook documented national and state level disparities in health care outcomes, access, and service utilization experienced by rural minorities. We chose to explore the specifics of preventive-service delivery disparities due to the variable rates we found in this chartbook, in an attempt to explain the factors related to utilization.

The analysis utilized the 2008 Behavioral Risk Factor Surveillance System (BRFSS); this is a nationally-representative survey of more than 300,000 adults regarding their health, health behaviors, and service utilization. We chose three services that have an A recommendation from the US Preventive Services Task Force: breast cancer screening, cervical cancer screening, and colorectal cancer screening. We followed their guidelines for recommended ages at screening, mode of screening, and frequency of screening. Our main variables of interest were rurality and race of the respondents. We defined the rurality of the respondents’ residence using urban influence codes; urban included all metropolitan counties; large rural included all counties with an urban core of 10,000 residents; small rural included all other counties.

Our findings indicated a disparity in preventive service delivery for these services. Rural women were less likely to receive either breast cancer or cervical cancer screenings; the proportion was lowest among residents of small rural counties. For example, 82.0% of urban women met the recommendations for breast cancer screening, compared to 78.7% of large rural and 75.3% of small rural women. Surprisingly, however, African American women in urban areas were more likely to be screened for breast or cervical cancer than whites; there were no significant differences by race within rural areas.

Similar trends were seen for colorectal cancer screening; rural residents were less likely to be screened than their urban counterparts. Once again, African American respondents were more likely to be screening than whites in both urban and large rural areas.

The final step of the analysis was to attempt to identify those factors that could help explain these disparities in service utilization. In these multivariate models, we included factors associated with general health services use, such as age, gender, educational attainment, income, insurance status, having a usual source of care, health status, and local physician supply. This analysis found that African American women, even in rural areas, were more likely to be screened than whites, all else held equal. The most substantial contributory factor to all service delivery was having has an exam with a physician in the previous year; those with an exam has an odds of service receipt ranging from 3.41 to 5.43. Having a usual source of care was also a strong predictor of service utilization. Socioeconomic status was also associated with service delivery, though not as strongly; those with insurance or higher incomes were also more likely to be screened. Despite controlling for all these associated factors, living in a rural area was still associated with lower odds of screening, particularly for breast and cervical cancer.

The strong effect sizes associated with having a usual source of care confirm previous studies indicating that a usual source of care has a substantial positive impact upon preventive services delivery (1-5) and controlling for these differences in provider availability alleviates or eliminates many racial differences in service delivery (6). Improving access to primary care, particularly in rural areas, may help to alleviate these disparities in preventive service delivery.

The higher screening rates that persisted even in the adjusted analysis are surprising, given the fact that minorities are less likely to have a usual source of care and typically have fewer physician encounters than whites (7,8). These higher rates among African American women may be indicative of the success of interventions aimed at improving preventive service utilization among minority groups, such as the National Breast and Cervical Cancer Early Detection Program (9). It is important to understand how these interventions were implemented and succeeded in order to continue reducing disparities in service provision, particularly for other services such as colorectal cancer screening.

Finally, the impact of socioeconomic status cannot be overlooked either. The Patient Protection and Affordable Care Act (PPACA) will help to address one barrier by requiring most insurance plans to provide preventive care services with no out-of-pocket patient costs. The PPACA will also provide insurance coverage for a large number of those currently without coverage, also enabling service delivery. It remains to be seen, however, if having insurance coverage will be sufficient to increase utilization, particularly in rural areas where there are a limited number of primary care providers. Existing programs, such as community health centers and the National Health Service Corps that place providers and facilities in these types of areas would be vital to ensure access to and delivery of these services for underserved women.

References:

1. Ettner SL. The timing of preventive services for women and children: the effect of having a usual source of care. Am J Public Health. 1996;86(12):1748-1754.

2. Gornick ME, Eggers PW, Riley GF. Associations of race, education, and patterns of preventive service use with stage of cancer at time of diagnosis. Health Serv Res. Oct 2004;39(5):1403-1427.

3. Kang-Kim M, Betancourt JR, Ayanian JZ, Zaslavsky AM, Yucel RM, Weissman JS. Access to care and use of preventive services by Hispanics: state-based variations from 1991 to 2004. Med Care. 2008;46(5):507-515.

4. O'Malley AS, Mandelblatt J, Gold K, Cagney KA, Kerner J. Continuity of Care and the Use of Breast and Cervical Cancer Screening Services in a Multiethnic Community. Arch Intern Med.1997;157(13):1462-1470.

5. Sambamoorthi U, McAlpine DD. Racial, ethnic, socioeconomic, and access disparities in the use of preventive services among women. Prev Med. 2003;37(5):475-484.

6. Williams RL, Flocke SA, Stange KS. Race and Preventive Services Delivery Among Black Patients and White Patients Seen in Primary Care. Med Care. 2001;39(11):1260-1267.

7. Stevens G, Shi L. Racial and ethnic disparities in the primary care experiences of children: a review of the literature. Med Care Res Rev. 2003;60:3-30.

8. Weinick R, Zuvekas S, Cohen J. Racial and ethnic differences in access to and use of health care services, 1977 to 1996. Med Care Res Rev. 2000;57(suppl 1):36-54.

9. Adams EK, Nancy B, Peter JJ. Impact of the National Breast and Cervical Cancer Early Detection Program on mammography and pap test utilization among white, Hispanic, and African American women: 1996-2000. Cancer. 2007;109(S2):348-358.

Socioeconomic status and Latina health

Feature Article: Gallo, L. C., Fortmann, A. L., Roesch, S. C., Barrett-Connor, E., Elder, J. P., Espinosa de los Monteros, K., Shivpuri, S., Mills, P. J., Talavera, G. A., & Matthews, K.A. (2011 epub). Socioeconomic status, psychosocial resources and risk, and cardiometabolic risk in Mexican-American women. Health Psychology, online November 2011.

Comment by: Linda C. Gallo, Ph.D., Professor of Psychology, San Diego State University, and Senior Core Investigator, Institute for Behavioral and Community Health, and Addie L. Fortmann, M.S., Doctoral Candidate, SDSU/UCSD Joint Doctoral Program in Clinical Psychology.

Over the past two decades, the US population has experienced alarming increases in rates of obesity and related conditions, such as the metabolic syndrome, a clustering of cardiovascular and metabolic risk factors that is closely linked with obesity and insulin resistance, and which portends high risk for future cardiovascular disease and diabetes. These trends have disproportionately affected individuals with low socioeconomic status (SES) and racial/ethnic minorities, including Latinos. Furthermore, such disparities are often more dramatic in women when compared with men. For example, whereas Mexican American women had a metabolic syndrome prevalence of 40.6% in 2003-2006, compared to 31.5% of non-Hispanic white women, the prevalence rate was lower in Mexican-American men (33.2%) when compared with their non-Hispanic white counterparts (37.2%; Ervin, 2009). Some studies also suggest a stronger socioeconomic gradient in the metabolic syndrome in women than in men (e.g., Loucks, Rehkopf, Thurston, & Kawachi, 2007).

Although many factors may contribute to health disparities, our lab has been particularly interested in the contributions of psychosocial factors. Specifically, individuals with minority ethnicity or lower SES may experience worse health outcomes in part due to heightened exposure to psychological stress and negative emotions, combined with reduced intrapersonal and interpersonal resources available to manage stressful and demanding environments (Gallo, Espinosa de los Monteros, & Shivpuri, 2009; Gallo & Matthews, 2003). To explore this hypothesis, we examined the extent to which psychosocial factors explained socioeconomic gradients in the metabolic syndrome in Mexican American women, about whom little is known regarding the roles of socioeconomic and psychosocial factors in health. Women of Mexican descent (N=304, aged 40-65 years) were recruited from socioeconomically diverse South San Diego communities that evidence a rich blend of Mexican and US cultural influences. Women underwent a clinical exam with fasting blood draw and completed measures of sociodemographic and psychosocial factors. Structural equation modeling was used to examine the links between socioeconomic status (income, education), psychological risk factors (i.e., negative emotions and cognitions) and resource factors (i.e., intrapersonal resources, such as optimism and self-esteem; interpersonal resources, such as social support), and metabolic syndrome components of blood pressure, lipids, abdominal obesity, and glucose regulation. Since a growing body of research suggests that the typically observed inverse SES-health gradients are sometimes inconsistent in Latinos and, in particular, may be flattened in less acculturated or immigrant Latino subgroups, we examined the hypothesized models separately in women who completed their interviews in English versus Spanish (a proxy for higher versus lower US acculturation).

Single latent constructs were found to represent SES indicators and psychosocial variables, whereas three factors were found to underlie the metabolic syndrome, i.e., blood pressure (systolic and diastolic), lipids (high-density lipoprotein cholesterol and triglycerides), and metabolic dysregulation (waist circumference and fasting glucose). Structural equation models indicated that women with lower SES evidenced higher metabolic syndrome risk, particularly on indicators capturing metabolic dysregulation (p < .05), and showed greater aggregate psychosocial risk/reduced resources (p < .001). In addition, the association between SES and metabolic syndrome risk was accounted for in part by psychosocial factors (p < .05). However, language stratified analyses showed that these associations were most relevant among higher US acculturated women, in whom lower SES was significantly associated with higher risk on all components underlying the metabolic syndrome, i.e., blood pressure, lipids, and metabolic dysregulation (all ps < .05), and in whom psychosocial factors contributed significantly to the SES and metabolic factor association (p < .05). In less US acculturated women, lower SES was associated with significantly higher risk on the metabolic dysregulation component only (p < .05), and psychosocial factors did not contribute significantly to this relationship. Other variables, such as health behaviors or environmental influences, may play a more salient role in SES gradients in less acculturated women. In addition, SES gradients may be attenuated in less acculturated Latinos because they benefit from cultural resources that help buffer the effects of low SES environments. However, because SES and acculturation are closely related, untangling their unique effects is extremely difficult. Overall, the study suggests the possible utility of incorporating techniques to reduce psychological distress and build resources in interventions that seek to address elevated cardiometabolic risk in Mexican American women. In addition, findings point to the importance of concurrently examining SES and cultural gradients in cardiometabolic risk, and in considering additional intermediate pathways that may have relevance across acculturation levels in Mexican American women, such as culturally-driven social or behavioral factors.

References:

Ervin, R.B. (2009). Prevalence of metabolic syndrome among adults 20 years of age and over, by sex, age, race and ethnicity, and body mass index: United States, 2003-2006. National Health Statistics Reports (13), 1-7.

Gallo, L.C., Espinosa De Los Monteros, K., & Shivpuri, S. (2009). Socioeconomic status and health: What is the role of reserve capacity? Current Directions in Psychological Science, 18(5), 269-274.

Gallo, L.C., & Matthews, K.A. (2003). Understanding the association between socioeconomic status and physical health: do negative emotions play a role? Psychological Bulletin, 129(1), 10-51. \

Loucks, E.B., Rehkopf, D.H., Thurston, R.C., & Kawachi, I. (2007). Socioeconomic Disparities in Metabolic Syndrome Differ by Gender: Evidence from NHANES III. Annals of Epidemiology, 17(1), 19-26.

Other Resources:

Abate, N., & Chandalia, M. (2011). Ethnic differences in the metabolic syndrome
In Grundy (Ed.), Atlas of Atherosclerosis and Metabolic Syndrome. (pp. 195-206): Springer New York.

Alberti, K.G.M.M., Eckel, R.H., Grundy, S.M., Zimmet, P.Z., Cleeman, J.I., Donato, K.A., et al. (2009). Harmonizing the Metabolic Syndrome: A Joint Interim Statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation, 120(16), 1640-1645.

Braveman, P.A., Cubbin, C., Egerter, S., Williams, D.R., & Pamuk, E. (2010). Socioeconomic Disparities in Health in the United States: What the Patterns Tell Us. American Journal of Public Health, 100(S1), S186-196.

Goldbacher, E.M., & Matthews, K.A. (2007). Are psychological characteristics related to risk of the metabolic syndrome? Annals of Behavioral Medicine, 34(3), 240-253.

Matthews, K.A., & Gallo, L.C. (2010). Psychological perspectives on pathways linking socioeconomic status and physical health. Annual Review of Psychology, 62(1), 501-530

Risk factors for Lung Cancer

Feature Article: Chiu, Y. L., Wang, X. R., Qui, H. & Yu, I. T. (2010). Risk factors for lung cancer: A case-control study in Hong Kong women. Cancer Causes & Control, 21, 777-785.

Comment by: Xiao-Rong Wang, Ignatius Tak-Sun Y, School of Public Health and Primary Care, the Chinese University of Hong Kong, Shatin, New Territories, Hong Kong Special Administrative Region, China

Lung cancer is a leading cause of cancer mortality in Hong Kong women, accounting for about one third of cancer deaths. Its age standardized incidence rate reached the highest around the world in the early 1990s. The similar high incidence and mortality rate were also reported among Chinese women living in mainland China, as well as in other countries, indicating ethnic disparities in women’s health. What really puzzled us was that unlike women in western countries, Chinese women had such a low prevalence of smoking as ranging from 3% to 5%. This made the health disparities among women difficult to explain. To identify etiological connections of lung cancer, we conducted this case-control study among 279 female lung cancer cases and 322 controls in Hong Kong, aged between 30 and 79 years. All of the lung cancer cases were confirmed histologically. We used multivariate approaches to determine significantly predictive variables for lung cancer among various potential risk factors, including cooking habits, dietary habits, occupational history, smoking, domestic environmental exposures, and family history of cancer and others.

We found the factors associated with increased lung cancer risk were smoking, family cancer history and exposure to radon at home. Among dietary factors, increasing consumption of meat was linked to a higher risk, whereas consumptions of vegetables had a strong protective effect against the disease. Moderate consumption of coffee had a beneficial effect. More importantly, we observed that exposure to cooking emissions significantly increased the risk, which contributed to 35% of population attributable risk in the nonsmokers, the highest fraction among these factors. Moreover, among the four categories of occupations (i.e., professional/clerical/sales; never employed/domestic helper; cleaners; construction/industry/sewer workers), the greatest risk was seen in the never employed/domestic helpers, with adjusted risk of 2.6 times, in comparison with clerical/sales workers. This, in turn, corroborated the role of cooking fumes as a risk factor for lung cancer, because housewives and domestic helpers were involved more cooking practice at home. The result suggests that among others, Chinese style cooking emission produced by fry, stir-fry and deep-fry at least partly is responsible for the high incidence of lung cancer in the women. This may also explain in part the ethnic disparities of the disease in women. The study also highlights the importance and necessity of initiating /strengthening education programs that focus on individual behavior and dietary habit changes in prevention and control of lung cancer in a population level.

Smoking and Lung Cancer

Feature Article: Ensminger, M. E., Clegg Smith, K., Juon, H., Pearson, J. L. & Roberston, J. A. (2009). Women, smoking and social disadvantage over the life course: A longitudinal study of African American women. Drug and Alcohol Dependence, 104, S34-S41.

Comment by: Dr. Margaret Ensminger

Smoking is the most preventable cause of death in the United States. As information about the damaging health effects of smoking has become more available, those with higher socioeconomic status have been less likely to initiate smoking and more likely to quit smoking. Consequently, there now exist disparities in smoking behavior in the United States such that those who are less educated and poor are more likely to be smokers, changing an earlier pattern where those with more resources did not differ from those with fewer resources in their likelihood to be smokers. This follows the pattern suggested by the “fundamental cause hypothesis” that socioeconomic disparities in health are maintained even (or especially) when specific health problems become better understood (Link and Phelan, 1995).

A question from the life course perspective is how much early life disadvantages contribute to health disparities in later life. In our study of a longitudinal cohort of African Americans from a disadvantaged community in Chicago followed from ages 6 to 42, we examined the antecedents of smoking at age 42 among the women (Ensminger, M. E., Smith, K. C., Juon, H. S., Pearson, J. L., & Robertson, J. A. (2009). Women, smoking, and social disadvantage over the life course: A longitudinal study of African American women. Drug and Alcohol Dependence, 104S, S34-S41). We found that women who were poor as children, became teenage mothers, dropped out of school, and were poor as young adults were much more likely to be smokers than women without these circumstances. However, in multivariate analyses, neither poverty during childhood nor poverty during adulthood were directly related to smoking status in adulthood. Rather, advantages in social capital over the life course were protective against later smoking. Those women who had better parental supervision during adolescence, had mothers who had not smoked, and were themselves involved in church during adulthood were less likely to be smokers as adults. Also, those who were current smokers had attained less schooling than both those who never smoked and those who had quit smoking. These findings indicate that early life advantages do make important contributions to later health behavior–in this case smoking.

Even within this relatively homogeneous population (same race, gender, age, and community origins) we find that differences in education and family social capital early in the life course matter for smoking behavior among adult women 20 to 30 years later. A life course perspective that takes into account the differing resources over various stages of life indicates that health disparities emerge within a developmental and historical context.

This conclusion is consistent with other work from this longitudinal study and others that have examined the early antecedents to drug use, criminal behavior, educational attainment, and mortality. These studies have shown the importance of the early school and family context. They lend strong support to health research as well as behavioral and educational research that explores factors in childhood and adolescence that may relate to problems that emerge later in life. The policy implications suggest more attention to the developmental pathways of problems over a long period of time with a focus on the earlier stages of life, in the hope of avoiding (i.e., preventing) later health or social problems.

Supplemental Lung Cancer Resources:

Bausewein C, Booth S, Gysels M, Higginson IJ. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD005623

Belani, C. P., Marts, S., Schiller, J. & Socinski, M. A. (2007). Women and lung cancer: Epidemiology, tumor biology, and emerging trends in clinical research. Lung Cancer, 55, 15-23.

Centers for Disease Control and Prevention. (2009, May 27). Lung cancer statistics.

Egleston, B. L., Meireles, S. I., Flieder, D. B. & Clapper, M. L. (2009). Population-based trends in lung cancer incidence in women. Seminars in Oncology, 36, 506-515.

Harichand-Herdt, S. & Ramalingam, S. S. (2009). Gender-associated differences in lung cancer: Clinical characteristics and treatment outcomes in women. Seminars in Oncology, 36, 572-580.

Niaura, R. & Abrams, D. B. (2002). Smoking cessation: Progress, priorities, and prospectus. Journal of Consulting and Clinical Psychology, 70, 494-509.

Parsons, A., Daley, A., Begh, R., & Aveyard, P. (2010). Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis: systematic review of observational studies with meta-analysis. BMJ (Clinical Research Ed.), 340b5569.

Patel, J. D. Lung cancer: a biologically different disease in women? Womens Health, 5, 685-691.

Peraman, T. (2008). Psychosocial factors in lung cancer: Quality of life, economic impact, and survivorship implications. Journal of Psychosocial Oncology, 26, 69-80.

Plunkett, T. A., Chrystsal, K. F. & Harper, P. G. (2003). Quality of life and the treatment of advanced lung cancer. Clinical Lung Cancer, 5, 28-32.

Ryan, L. S. (1996). Psychosocial issues and lung cancer: A behavioral approach. Seminars in Oncology Nursing, 12, 318-324.

General Resources:
SAMHSA’S National Mental Health Information Center: Office on Women’s Health

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