Black Women in Rural Communities: Unraveling Health Disparities

Faye A. Gary Case Western Reserve University

Gloria B. CallwoodUniversity of the Virgin Islands

Hossein N. YarandiDoris W. Campbell

University of South Florida (Ret)University of the Virgin Islands

Suzette LettsomeUniversity of the Virgin Islands

Edith Ramsey JohnsonUniversity of the Virgin Islands

Purpose • Discuss factors influencing women’s health issues

in local communities---including conceptual frameworks

• Present findings from an Empirical Study about African American Women in a Rural Community

• Share qualitative data from Focus Groups of African American Women

• Provoke discussions about the health status of women and its relationship to the social determinants of health

WHO

• Gender is used to describe those characteristics of women and men which are socially constructed

• Sex is biologically determined

• People are born female or male but learn to be girls and boys ----who grow into women and men. This learned behavior makes up gender identity and determines gender roles.

Source: Abou-Gareeb, Lewallen, Bassett and Coutright. Gender and blindness: a meta-analysis of population based prevalence surveys. Opthalmic Epidemiology 2001; 8:39-56

Women64%

Men36%

Burden of Blindness in Men and Women

Source: Abou-Gareeb, Lewallen, Bassett and Coutright. Gender and blindness: a meta-analysis of population based prevalence surveys. Ophthalmic Epidemiology 2001;8:39-56; Barry, M. (2004) Yale University

BURDEN OF BLINDNESS IN MEN AND WOMEN

Frameworks• Numerous Frameworks Developed to Examine

Health Disparities– Comprehensive framework of the determinants

of health. George Kaplan, 1999.– Framework for human development and the

social determinants of health. Hertzman, 1999. – Model for the pathways by which SES may affect

health. Baum et al., 1999.– MacArthur Foundation Research Network in

Socioeconomic Status and Health model of pathways from SES to health, 2000

– Social Determinants of Health. Marmot & Wilkerson, 1999; 2006.

Individual/Population Health

Pathophysiological pathways

Genetic/Constitutional Factors

Individual Risks

Social Relationships

Living Conditions

Neighborhood/Communities

Institutions

Social and Economic Policies &

Environment

Life course

Kaplan, 1999

Human Life Cycle

Birth

Death

Social

Network

Civil Society

National Socio-Economic Environment

Hertzman, 1999

SES

Neighborhood or Community Hazards and Supports

STRESS

Social Conditions (e.g., Discrimination, Exclusion) That Are Correlated With SES

Other Aspects of SES That Affect Health (e.g., Access to Medical Care, Nutrition, Role Models)

Behaviors That Impair or Support Good Health-Tobacco Use- Exercise

Biological Changes in Systems-Immune System- Endocrine System

Changes in Illness-Related Behavior-Prevention - Early detection

Health Outcomes

SESEducation Occupation

Income Subjective SESSES Inequality

Race Gender

Environmental Resources & Constraints

Neighborhood FactorsSocial Capital

Work SituationFamily Environment

Social SupportDiscrimination

Psychological InfluencesResilience/Reserve Capacity

Negative Affect (anxiety, depression, hostility)

Negative ExpectationsPerceived Discriminations

Reactive Responding

Access to Medical Care

Exposure to Carcinogens &

Pathogens

Health-Related Behaviors

Central Nervous System & Endocrine Response

Health Cognitive FunctionPhysical Function

Disease

Disease TrajectoriesRecovery Relapse

Secondary Events

Mortality

Health Outcomes

Life Course

Social Structure

Social Environment

Material Factors

Work

Psychological

Brain/Neuro-Endocrine &

Immune ResponseHealth

Behaviors

Early life

GenesGenotypes

CultureEthnicity

Pathophysiological Changes

Well-beingMorbidityMortality

Social Determinates of Health

Marmot, M., &. Wilkinson. (2006). Social Determinants of Health. New York: Oxford University Press .

Women’s Health

An Empirical Study

Relationship between Personal Knowledge, Social Support Systems, Menopausal Symptoms, Self-care, Depressive Symptoms, Stress, and Health Status among Southern Rural African American Menopausal Women

Introduction

• The social determinants of health and its relationship to the well-being of Black women is seldom researched and often overlooked in practice and health policy

• Stress manifests itself as a disturbance in mood with common symptoms such as persistent sadness or despair, insomnia, decreased appetite, hopelessness, irritability, low self-esteem and suicide

Background

• Black women are on the top 10 list of diseases and disorders

– They typically are undiagnosed or under diagnosed with depression, anxiety, sleep disorders, and other mental health related disorders

– Blacks are more likely to receive care in the primary care sector, but disparities exist in both the recognition of psychological stress disorders, and subsequent treatment

Stress

• Irritating, conflicting, frustrating, and distressing demands that occur in everyday transactions

• Examples include

– Arguments with family members or friends

– Deadline pressures

– Financial difficulties

– Sleep disturbance

– Multiple responsibilities that need attention

Health

• Differences in Health Status Among Black Women Related to: – Lower Socioeconomic Status

– Daily Hassles

– Unfair Treatment in Society

– Acute Life Events

– Cumulative Stress

Participants• The sample consisted of 206 Black

women at various rural sites within a 50-mile radius of a large university.

• The participants were between 40 and 60 years of age, and all of them resided in rural communities.

Methods

• Survey data from 206 black women were used in this study

• Face-to-face interviews that lasted about one hour in duration

• Items were read aloud to the women to avoid the need to query them about their reading levels

Measures

• Demographic Data Form

• Menopausal Health Survey

• Life Stress Questionnaire

• Beck Depression Inventory

• People in Your Life Inventory

Marital Status

Health Status (Self Report)

Payment for Medical Care

Demographic Characteristics

• Mean Age = 48.09 (SD = 6.45)

• Mean Education = 13.5 (SD = 7.02)

• Married = 61%• Employed = 62%• Protestant = 89%• Insurance = 89%

Menopause Knowledge: After menopause, women’s risks of heart

attachs:

Menopause Knowledge: Hot flashes can be reduced by:

Health Promotion

I watch my diet

Health Promotion I do planned

exercises

Health Promotion

I take vitamins, herb, mineral or calcium supplements

Take on a greatly increased workload

How stressful was the event to you?

Separated from mate for more than two weeks due to argument or discord

How Stressful was the event to you?

Close Friend or relative had major change in health status

How stressful was the event to you?

Close friend or family member involved in crime or legal matterHow stressful was the event to you?

Chronic Financial StressHow stressful was the event to you?

Findings

• No Association between Health Status & Insurance

• Positive Relationship between Health Status & Employment (chi-square = 33.26, p = 0.0001)

• Odds Ratio of Unfavorable Health Status & Unemployment Was 6.17 Times Higher Than Women with Favorable Health Status & Employed

Findings

• Among Those with Unfavorable Health Status, 66.67% Were Unemployed, While Only 24.48% of Those with Favorable Health Status Were Not Fully Employed.

• A Non Employed Black Woman Had a 86.05% Probability of Having an Unfavorable Health Status

Findings

• Characteristics of the Women with Favorable Health Status:– More Educated ( t = 2.98, p < 0.0032)– Higher Incomes (z = 4.34, p < 0.0001)– Incurred Less Out of Pocket $ for Medications

( t = 8.40, p < 0.0001) – Higher Scores in Health Knowledge

(z = 4.15, p < 0.0001) – Higher Scores in Decision Making (z=8.98, p <0.0001)– Higher Scores in Controlling Menopause Symptoms (z = 8.98, p

<0.0001)– Higher Scores in Health Promotion (z = 6.96, p <0.0001)– Higher Score in Self Perceptions (z = 5.82, p < 0.0001)– Lower Score in Life Experiences (z = 6.09, p <0.0001)

Findings

• Characteristics of the Women with Favorable Health Status– Fewer Unpleasant/Distressing Social Interactions

(z = 7.88, p < 0.0001)– More Pleasant Events in Their Lives

(z = 7.66, p <0.0001) – More Active in Participating in Support Groups and

Health Related Organizations (z = 3.00, p = 0.0027). – Between the two groups, no significant differences in

• the Mean Age (t = 1.37, p = 0.1731), • Beck Depression Score (z = 0.33, p = 0.7387), • Life Stress Score (z = 1.077, p = 0.2826), • People Interactions Score (z = 0.99, p = 0.3193)

Findings: Logistic Regression • Statistically Significant Variables Were:

– Health Knowledge– Controlling Menopause Symptoms – Experiencing Pleasant Life Events– Unpleasant/Distressing Social Interactions– Self Perceptions

• Women who self-reported favorable heath status had:– 1.83 times higher health knowledge, – 1.61 times better control of menopause

symptoms, – 1.65 times more pleasant life events, – 2.43 times higher self perceptions than those

who reported unfavorable heath status

Total Scores

Range

0-1314-1920-2829-63

MinimalMild

ModerateSevere

Beck Depression Scale Total Score Distribution

Beck Depression Scale Total Score Distribution for the Sample

Factor Analysis of DBI-II• Evidence of the BDI factorial validity is provided by

the intercorrelations among the 21 BDI items, which were first calculated from the responses of the sample of 206 Black Women.

• Kaiser's measure of sampling adequacy for this matrix was 0.92, a value that Kaiser considered to be “marvelous.”

• An iterated principal-factor analysis was performed in which squared multiple correlations were employed for the initial communality estimates, and a Promax (oblique) rotation was used to identify the self-reported dimensions of depression.

Factor Analysis of DBI-II

• Two factors were extracted, they explained 83% of the common variance.

• Two comparably sized eigenvalues of 5.34 and 5.53 were found for the reduced correlation matrix and the correlation between the two oblique factors was 0.57 (p < 0.001).

Factor Analysis for a Sample of (N=206) Black Women

Factor I Factor IISymptom Pessimism 0.81 -0.22 Worthlessness 0.73 -0.10 Punishment Feelings 0.65 0.03 Sadness 0.45 0.19 Self-Dislike 0.44 0.15 Loss of Interest 0.44 0.25 Indecisiveness 0.43 0.22 Past Failure 0.40 0.12 Guilty Feelings 0.35 0.28 Self-criticalness 0.34 0.28 Suicidal Thoughts or Wishes 0.28 0.17 Tiredness or Fatigue -0.03 0.76 Loss of Energy -0.06 0.63 Concentration Difficulty 0.12 0.58 Irritability 0.15 0.55 Changes in Appetite -0.01 0.54 Changes in Sleeping Pattern 0.16 0.51 Loss of Interest in Sex -0.07 0.48 Loss of Pleasure 0.21 0.42 Crying 0.27 0.34 Agitation 0.28 0.34

Pattern Matrix for the Factor Analysis of Beck Depression Scale-II

Factor Interpretation• Symptoms such as Pessimism,

Worthlessness, Punishment Feelings, Sadness, Self-Dislike, Loss of Interest, Indecisiveness, and Past Failure tended to load high on the first factor. All of these symptoms were psychological and cognitive in nature. Therefore, this factor was considered to reflect a Cognitive dimension of self-reported depression.

Factor Interpretation

• The second factors explained somatic symptoms, such as Tiredness or Fatigue, Loss of Energy, Concentration Difficulty, Irritability, Changes in Appetite, Changes in Sleeping Pattern, Loss of Interest in Sex, and Loss of Pleasure. The factor was considered to represent a Somatic- Affective dimension of self-reported depression.

Naming the Factors • Factor I can be named as “critical self

appraisal.” The variables included in Factor 1 are cognitive in nature and indicate that the women are critical of themselves, devalue their significance, and internalize thoughts that constitute a negative self-view.

• Factor II can be named “deregulation of arousal.” It is related to physiological changes that occur among individuals.

Focus Group•Two focus groups were conducted.

•Each focus group consisted of 10 participants.

•The participants were chosen randomly from the sample of 206 African American Women.

Responses to One Query

• What Do You Think are the Barriers or the Stumbling Blocks to Black Women Receiving Good/High Standard Healthcare?

Focus Group Data

• Mary: ( A lovely experience) “ The doctor I am on, I love him. I love him to death. He retired and I hate that.” “He was honest to you—he told you the truth. He explains everything.” “ Some doctors give you free samples—and some of these doctors won’t give you no free samples. They ask, “Do you have insurance? Can you pay a co-pay? They leave me out in the cold. “ ….. And he’ll say…….We will give you a month’s free supply—if you run out and don’t have no money for it, come back to the office…..we will see what we got.”

Focus Group Data

• Miriam: ….”Some of them will get you in and out of that office as quick as they can…...”

• “Ya, Okay, Ya, Breath In, Okay ; Breath out, Ya—Okay. ..Now open your mouth, Ya—Okay. And then you out!”

• I say, “Wait a minute—come back and have a seat cause we need to talk—cause I had a lump one time in my breast and Lord know I was afraid-----I walked around with the lump for six months, cause you …don’t want to hear no bad news.”

Focus Group • Miriam: …..”I can’t have no surgery. “

• “ He said…..Well, you don’t tell me what to do. I am the doctor, so I am going to make all these decisions for you.” …….Do you have insurance?” “Insurance ain’t the problem.”

Focus Group Data

• Gladys: “He was young. He passed away. I have a bulge on my back…..out of work for three-four months…..I would go to him and I don’t know whether…because I was Black or what…or the xxxxx type of Insurance…this doctor didn’t do nothing—and when he would come in …. he would cross his leg and sit in the corner and say …

• “How you do? You doing fine.” • “ Well, my back is bothering me.” • “ Well, it’ll get better. Sign the paper…..Well, take

this (write a prescription and place it on the table). That doctor do not put his hands on me, period!”

Focus Group Data

• Cheryl: “Doctors don’t sit down and talk---face-to-face----we have a lot of them (family and friends) that don’t have insurance and their scared to come to the hospital---cause they don’t have no insurance. It ain’t right.”

• Barbara: “ …He (doctor) just didn’t have time for me..and I hated to come here….when you call back and ask a question, they tell you… Make a appointment …and then you have to come back and pay again. “ You just forget it.”

Focus Group Data

• Ann: ….with Medicaid and Medicare, we got a lot of them saying….Well, we don’t take Medicaid and Medicare. I forgot if it is in the house or the senate, wherever…..they going to use experimental drugs on these people who are on Medicaid and Medicare and that’s wrong! Give them the good kind of medicine---I tell my doctor---Don’t write me no generic prescription, I want the PRESCRIPTION! When you are sixty-five and not working no more…..you go on Medicare and Medicaid…they not concerned about you.

There is a special place where they put you if you on Medicaid or Medicare. You know that West Wing back there at xxxx Hospital? That just where they put you.”

Focus Group DataJewel: “What you are saying is not surprising-My dad had to be intubated. They assume that because you may be older and got grey hair, and you are along at admission, you have no family and friends. He was intubated; had not been shaved; half his cloths was hanging off of him; the canister was full; the urinal was full; his pressure was high (monitor); the monitor was going off. “ “I was upset!”

“ I am going downstairs, you need to get yourself together cause when I come back, I’m going to be ready. He is on a ventilator, he should be monitored! You thought he was thrown away…he is not indigent, and its definitely not that he doesn’t have family---if you don’t get him together before midnight tonight, he as five other children that will be here. Things changed! “

Focus Group DataJewel (Cont.): “Dad was moved to another room--- brother had to tell the nurse that she needed to clean up the man next to Dad because they had left him in a bad way; we negotiated for other people. If you don’t have nobody to speak up for you, you’re in trouble. “ Gloria: “ Black people…Cause they don’t trust people…and you see why! …Because you are Black..Okay—they don’t understand, they don’t listen to you…you can’t trust them …if you hear somebody talking about you, don’t say nothing…they are afraid they’ll be mistreated or somebody will do something vengeful against them ... Just don’t say nothing.”

Focus Group DataOllie: “To be frank…a lot of Black people ….when you go in

these offices and they (Whites) are more in power than you are….. (they think) “You are stupid….Instead of saying “Well, come on in….I can help you if you’ve got a problem.”

Joscelyn: Yeah….they turn up their noses at you, like maybe they don’t want to touch you cause you go to some of these clinics and everything. Some of them sit and look at you like you’re crazy…. like you might have AIDS or something….you got to tell them all, and say “Hey, I don’t have no AIDS, you can touch me!.” And listen to my pain, when I tell you where it is, you know….you want to go to one that will come in and say, “Where you hurting?”

IOM, 2003, P 127.

Recommendations• We Recommend that:

– Concerted community-based efforts be implemented to increase Black women’s knowledge levels about :• Stress and aggravation and its potential

influence on their physical and mental health status

• Expecting that culture -specific health teaching programs be developed to address stress, aggravation & their relationships to early morbidity/mortality

Recommendations

• Programs in Health Promotion and Disease Prevention should be Implemented in Communities

• Health Providers must become more culturally competent about and sensitive to the barriers and stumbling blocks that Black women perceive as interference to better healthcare and a higher quality of life

Recommendations

• Advocate for system changes that are perceived as stalemates to the effective and equitable delivery of health care

• Advance transformational science and practice research that relate the social determinants of health to high morbidity and mortality among vulnerable populations, including rural southern African American women

• Develop population-specific interventions to eliminate health inequities

Recommendations

• Advocate for political and social change and emphasize that “Place Matters” in morbidity, mortality, and well-being.

• Develop personalized and culturalized medicine that is patient-family focused

• Educate a diverse group of health providers • Expand heath education/literacy for all people

through the use of technology

Kleinman’s Explanatory Model

What do you call this problem?What do you think is the cause of the problem?What course do you think the illness will take? How serious is this problem?What do you think the problem does inside your

body?How does it affect your mind and your body?

What do you fear most about this condition?

What do you fear most about the treatment?

Recommendations

• What are your thoughts about improving health for marginalized, excluded, and

underserved persons?

THANK YOU

QUESTIONS AND DISCUSSION