Black Women in Rural Communities: Unraveling Health Disparities

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• 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
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Purpose

• 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

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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.

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Source Abou-Gareeb, Lewallen, Bassett
and Coutright. Gender and blindness a
meta-analysis of population based prevalence
surveys. Opthalmic Epidemiology 2001 839-56
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
2001839-56 Barry, M. (2004) Yale University
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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.

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

• An Empirical Study

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

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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

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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

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Health

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

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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.

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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

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Measures

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

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Marital Status
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Health Status (Self Report)
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Payment for Medical Care
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Demographic Characteristics

• Mean Age 48.09 (SD 6.45)
• Mean Education 13.5 (SD 7.02)
• Married 61
• Employed 62
• Protestant 89
• Insurance 89

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Menopause Knowledge After menopause, womens
risks of heart attachs
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Menopause Knowledge Hot flashes can be reduced
by
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Health Promotion
I watch my diet
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Health Promotion
I do planned exercises
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Health Promotion
I take vitamins, herb, mineral or calcium
supplements
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Take on a greatly increased workload
How stressful was the event to you?
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Separated from mate for more than two weeks due
to argument or discord
How Stressful was the event to you?
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Close Friend or relative had major change in
health status
How stressful was the event to you?
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Close friend or family member involved in crime
or legal matter
How stressful was the event to you?
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Chronic Financial Stress
How stressful was the event to you?
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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

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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

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Findings

• 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
  0.0001)
• Higher Scores in Decision Making (z8.98, p
  lt0.0001)
• Higher Scores in Controlling Menopause Symptoms
  (z 8.98, p lt0.0001)
• Higher Scores in Health Promotion (z 6.96, p
  lt0.0001)
• Higher Score in Self Perceptions (z 5.82, p lt
  0.0001)
• Lower Score in Life Experiences (z 6.09, p
  lt0.0001)

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Findings

• 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
  lt0.0001)
• 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)

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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

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

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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).

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

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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.

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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.

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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.

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Responses to One Query

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

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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
  got.

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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.

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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.

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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!

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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.

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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 more..you 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.

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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!
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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.
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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
  something.you 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 know.you want to go to one that will
  come in and say, Where you hurting?

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IOM, 2003, P 127.
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Recommendations

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

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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

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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

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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

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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
  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?

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Recommendations

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

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THANK YOU QUESTIONS AND DISCUSSION