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Black Women in Rural Communities: Unraveling Health Disparities


Black Women in Rural Communities: Unraveling Health Disparities Faye A. Gary Case Western Reserve University Gloria B. Callwood University of the Virgin Islands – PowerPoint PPT presentation

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Title: Black Women in Rural Communities: Unraveling Health Disparities

  • Black Women in Rural Communities Unraveling
    Health Disparities

Faye A. Gary Case Western Reserve
University Gloria B. Callwood University of the
Virgin Islands Hossein N. Yarandi Doris W.
Campbell University of South Florida
(Ret) University of the Virgin Islands Suzette
Lettsome University of the Virgin Islands Edith
Ramsey Johnson University of the Virgin Islands
  • Discuss factors influencing womens 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

  • 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 839-56
Source Abou-Gareeb, Lewallen, Bassett and
Coutright. Gender and blindness a
meta-analysis of population based prevalence
surveys. Ophthalmic Epidemiology
2001839-56 Barry, M. (2004) Yale University
  • Numerous Frameworks Developed to Examine Health
  • 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.

Kaplan, 1999
Hertzman, 1999
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Social Determinates of Health
Marmot, M., . Wilkinson. (2006). Social
Determinants of Health. New York Oxford
University Press.
Womens 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
  • 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

  • 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

  • Irritating, conflicting, frustrating, and
    distressing demands that occur in everyday
  • Examples include
  • Arguments with family members or friends
  • Deadline pressures
  • Financial difficulties
  • Sleep disturbance
  • Multiple responsibilities that need attention

  • Differences in Health Status Among Black Women
    Related to
  • Lower Socioeconomic Status
  • Daily Hassles
  • Unfair Treatment in Society
  • Acute Life Events
  • Cumulative Stress

  • 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

  • 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

  • Demographic Data Form
  • Menopausal Health Survey
  • Life Stress Questionnaire
  • Beck Depression Inventory
  • People in Your Life Inventory

Marital Status
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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, womens
risks of heart attachs
Menopause Knowledge Hot flashes can be reduced
Health Promotion
I watch my diet
Health Promotion
I do planned exercises
Health Promotion
I take vitamins, herb, mineral or calcium
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 matter
How stressful was the event to you?
Chronic Financial Stress
How stressful was the event to you?
  • No Association between Health Status Insurance
  • Positive Relationship between Health Status
    Employment (chi-square 33.26, p
  • Odds Ratio of Unfavorable Health Status
    Unemployment Was 6.17 Times Higher Than Women
    with Favorable Health Status Employed

  • Among Those with Unfavorable Health Status,
    66.67 Were Unemployed, While Only 24.48 of
    Those with Favorable Health Status Were Not Fully
  • A Non Employed Black Woman Had a 86.05
    Probability of Having an Unfavorable Health Status

  • Characteristics of the Women with Favorable
    Health Status
  • More Educated ( t 2.98, p lt 0.0032)
  • Higher Incomes (z 4.34, p lt 0.0001)
  • Incurred Less Out of Pocket for Medications ( t
    8.40, p lt 0.0001)
  • Higher Scores in Health Knowledge (z 4.15, p lt
  • Higher Scores in Decision Making (z8.98, p
  • Higher Scores in Controlling Menopause Symptoms
    (z 8.98, p lt0.0001)
  • Higher Scores in Health Promotion (z 6.96, p
  • Higher Score in Self Perceptions (z 5.82, p lt
  • Lower Score in Life Experiences (z 6.09, p

  • Characteristics of the Women with Favorable
    Health Status
  • Fewer Unpleasant/Distressing Social Interactions
    (z 7.88, p lt 0.0001)
  • More Pleasant Events in Their Lives (z 7.66, p
  • More Active in Participating in Support Groups
    and Health Related Organizations (z 3.00, p
  • 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
  • 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

Beck Depression Scale Total Score Distribution
Total Scores Range
0-13 14-19 20-28 29-63 Minimal Mild Moderate Severe
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

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 lt 0.001).

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

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 youhe told
    you the truth. He explains everything. Some
    doctors give you free samplesand some of these
    doctors wont 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
    hell say.We will give you a months free
    supplyif you run out and dont have no money for
    it, come back to the office..we will see what we

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,
    YaOkay. ..Now open your mouth, YaOkay. And
    then you out!
  • I say, Wait a minutecome back and have a seat
    cause we need to talkcause 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 dont want to hear no bad news.

Focus Group
  • Miriam ..I cant have no surgery.
  • He said..Well, you dont 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 aint 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 dont know
    whetherbecause I was Black or whator the xxxxx
    type of Insurancethis doctor didnt do
    nothingand 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, itll 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 dont sit down and
    talk---face-to-face----we have a lot of them
    (family and friends) that dont have insurance
    and their scared to come to the hospital---cause
    they dont have no insurance. It aint right.
  • Barbara He (doctor) just didnt 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 dont 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 thats wrong! Give them the good
    kind of medicine---I tell my doctor---Dont write
    me no generic prescription, I want the
    PRESCRIPTION! When you are sixty-five and not
    working no go on Medicare and
    Medicaidthey 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 Data
Jewel 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, Im going to be ready.
He is on a ventilator, he should be monitored!
You thought he was thrown awayhe is not
indigent, and its definitely not that he doesnt
have family---if you dont get him together
before midnight tonight, he as five other
children that will be here. Things changed!
Focus Group Data
Jewel (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 dont have nobody to speak up for
you, youre in trouble. Gloria
Black peopleCause they dont trust peopleand
you see why! Because you are Black..Okaythey
dont understand, they dont listen to youyou
cant trust them if you hear somebody talking
about you, dont say nothingthey are afraid
theyll be mistreated or somebody will do
something vengeful against them ... Just dont
say nothing.
Focus Group Data
  • Ollie To be franka 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 youve got a problem.
  • Joscelyn Yeah.they turn up their noses at
    you, like maybe they dont want to touch you
    cause you go to some of these clinics and
    everything. Some of them sit and look at you
    like youre crazy. like you might have AIDS or got to tell them all, and say
    Hey, I dont have no AIDS, you can touch me!.
    And listen to my pain, when I tell you where it
    is, you want to go to one that will
    come in and say, Where you hurting?

IOM, 2003, P 127.
  • We Recommend that
  • Concerted community-based efforts be implemented
    to increase Black womens knowledge levels about
  • Stress and aggravation and its potential
    influence on their physical and mental health
  • Expecting that culture -specific health teaching
    programs be developed to address stress,
    aggravation their relationships to early

  • 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

  • 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

  • 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

Kleinmans 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
  • 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?

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